EFS Referral Form

Patient Intake / Referral Form
Patient Demographics
Legal Name *

First Name Middle Name Last Name
Gender *

Male Female
Date of Birth *

Month Day Year
Date
Insurance Number
Insurance Type
Social Security Number
Referred Patient is an Adult? *

Yes No
Parent / Guardian *

First Name Last Name
Relationship
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Alternate Phone Number
Emergency Phone Number
Email
example@example.com
Ethnicity *
Primary Language
Medical / Psychiatric History
Previous Psychiatrist
Contact Info
Current Medications
Compliant?

Yes No
Prescribed By
Number of Hospitalizations
Last Date / Extent
Self-Mutilation?

Yes No
Last Time
Suicidal Ideation

Yes No
Last Ideation
Attempts

Yes No
Last Attempt
History of Substance Abuse

Yes No
Date of Last Use

Month Day Year
Date
Substance(s) of Choice
Frequency

Daily Weekly Monthly Rarely Socially Never
Any Other Health Conditions

Yes No
Explain
For example, hypertension, diabetes, high blood pressure, seizures, etc.
Chief Complaint

*REFERRAL IS INCOMPLETE WITHOUT THIS SECTION COMPLETED*
Brief History, Presenting Problem(s), Current Diagnosis *
Symptom / Problem Checklist *

Physical / Verbal Aggression Anxiety Conduct Problems Depressed Mood Elevated Mood Family Problems Gender Issues Grief Hyperactivity Independent Living Problems Irritability Mood Swings Oppositional / Defiant Behaviors Poor Concentration Poor Interpersonal Skills Poor Judgement PTSD/Trauma Home / Work / School Problems Self-Harming / Dangerous Behaviors Thoughts of Suicide History of Abuse Worthlessness At-Risk of Legal System Substance Use Court Ordered Sexually Acting Out
Referred By *
Contact Info *
*** REFERRAL is COMPLETE, unless the referral source is DFCS, Court, DJJ, or Mental Health Agency; please continue ***

If this is NOT a DFCS, Court, DJJ, or Mental health Agency referral, scroll to the bottom and click Submit.
DFCS / Foster Care, Court / DJJ or Mental Health Hospital, PLEASE fill out the portion that pertains to your entity type.
DFCS / Foster Care Referral
Department of Family & Children Services Case

Yes No
Supporting Documents

Browse Files
Completed CCFA, Trauma Assessment, Psychological, etc. Cancel of
County
Case Manager Name
Phone Number
Fax Number
Case Manager Email
Supervisor's Name
Placement Information (if other than Biological Parent or Legal Guardian)

Please submit copy of Guardianship / Placement Agreement
Supporting Documents

Browse Files
Guardian/Placement Agreement Cancel of
Name or Agency
Contact Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Type

Group Home Foster Home Temp Housing Extended Housing Non-Relative (Fictive Kin)
Dept. of Juvenile Justice / Court Referral
Court Ordered? (Drug Court, Dept. of Juvenile Justice, etc.)

Yes No
Supporting Documents

Browse Files
Completed CCFA, court recommendations, probation order, etc. Cancel of
County
Probation Officer Name
Probation Officer Phone
Probation Officer Fax
Probation Officer Email
example@example.com
Supervisor's Name
Presenting Charge / Offense
Next Court Date

Month Day Year
Date
Mental / Behavioral Health Hospital Referral
Mental/Behavioral Health Hospital Referral?

Yes No
Supporting Documents

Browse Files
Admission paperwork, discharge summary, last progress note, etc Cancel of
Name of Facility
Phone Number
Fax Number
Admission Date

Month Day Year
Date
Discharge (Anticipated) Date

Month Day Year
Date
Presenting Problems at Time of Admission
Discharging Therapist
Direct Contact Number
Medications Prescribed
Discharging Mental Health Diagnosis(es)
Supporting Documents

Browse Files
Please submit any documentation supporting the above diagnosis(es) Cancel of
Admin Notes
Notes:
Should be Empty:

Patient Intake / Referral Form

Patient Demographics

Medical / Psychiatric History

Chief Complaint

DFCS / Foster Care, Court / DJJ or Mental Health Hospital, PLEASE fill out the portion that pertains to your entity type.

DFCS / Foster Care Referral

Dept. of Juvenile Justice / Court Referral

Mental / Behavioral Health Hospital Referral