HARVEST OF HOPE

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Referral

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Thank you for referring this client to Harvest of Hope Behavioral Health. Please provide the following pertinent information and appropriate medical records (Most Recent Treatment Plans, Psychiatric Evaluations and/or Psychosocial Assessments, etc.) to ensure thorough and timely service

Initial Referral Date:

First Name

Date Of Birth

Concurrent Referral Date

Last Name

Parent /Guardian Name:

Address

Phone

Name of School (Minor)

Medicaid #:

Medications Names

Dosage

Frequency

If You Choose Other Specify

(MUST BE A LICENSED MENTAL HEALTH PROVIDER) Verbal Approval from Therapist to refer identified consumer for Psychiatric Rehabilitation services secured. I am authorized or have been given authorization to give consent for Harvest of Hope Behavioral Health PRP to collaborate with service providers to receive and verify the information on this form for screening assessment purposes, and to determine the appropriateness of services for above-referenced individual.

REFERRING PROVIDER/AGENCY INFORMATION NAME

Street Address:

City, State, Zip Code

Referring Phone Number

Position / Title

Referring Provider Signature

HARVEST OF HOPE

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Referral

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