Inpatient Referral Form

Inpatient Referral Form
Program Preference*
Date of Referral*

MonthDayYear
Date
Requested Start Date*

MonthDayYear
Date
Referring Agency Name*
Referring Provider Name*
Referring Provider Phone Number*
Referring Provider Email*
example@example.com
Patient Name*
Patient Date of Birth*

MonthDayYear
Date
Gender Identity*
If "Other, please specify in the field below
Pronouns*
If "Other", please specify in the filed below
Primary Language*
If "Other", please specify in the field below
Guardian if applicable*
Patient Phone Number*
Patient Email*
example@example.com
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Insurance*
Policy Number*
Secondary Insurance
Policy Number
Reason for referral (please list symptoms and relevant history*
Please describe relevant substance use*
Amount/frequency*
Date of last use

MonthDayYear
Date
Current Diagnoses*

Severe DepressionAnxiety DisorderSubstance UsePTSDADHDPersonality DisorderSchizophreniaSchitzoaffective DisorderBipolar DisorderOther
If "Other", please specify in the field below
Current medications (names & doses if available)*
Current living situation/transportation*
Is patient willing and able to participate in group based treatment?*
Safety Risks*

ElopementSuicidal IdeationSuicide AttemptsSelf HarmAggression and/or ViolenceFire StartingLegal ProblemsEating DisordersRecent Restraint(in past week)OtherNone
Please specify safety risks here*

Bournewood Health Systems

Inpatient Hospital Location Information

Brookline Inpatient Hospital Program

Phone: (617) 676-3620

Fax: (857) 277-5923

Please attach the following clinical documentation if available:

Please upload any clinical information*

Cancelof
I agree that the above information is accurate to the best of my knowledge, and I understand that any intentionally inaccurate information or omissions may result in this referral being declined.
Referral Source Signature

Clear
Date

MonthDayYear
Date
Patient or Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty: