bridgeway pc / ho / sh / pact referral form

PC / HO / SH / PACT REFERRAL FORM

This Referral Form is a Fillable PDF. Download and save this form to retain data. Fax the completed form to the appropriate program’s fax number listed on the bottom of page 4 of this form.

REFERRAL SOURCE INFORMATIONToday’s Date:

Name of Referrer:Name of Referring Agency:

Agency Phone:Agency Fax:

___________________________________________________________________________________________________________________

STATE PH/PCVNAICMSPACT

STCFIPUER

Referring Agency is: (check, if applicable)

INSTRUCTIONS

Bridgeway Behavioral Health Services PC/HO/SH/PACT General Referral Form - Fillable PDF - Last Revised 07/29/2021 of 4

The latest edition of this form may be found at https://www.bridgewaybhs.org/pubs/form.referral.general.pdfBehavioral Health ServicesBridgeway

BENEFIT AND INSURANCE INFORMATION

Name of Payee:Street, City, State, Zip:

______________________________________________________________________________________________________________________________________________________

Medicaid #SSI $

Pension / VA $

Medicare #SSD $

Other $

PAAD #Welfare $

None

Private Ins#Salary $

Unknown

________________________

________________________

________________________

________________________

Payee Phone:

PERSON SERVED PERSONAL AND DEMOGRAPHIC INFORMATIONName of Person Served:

Street Address:City:

State:Email Address:

_________________________________________________________________________________ Zip: ______________________________________

Male FemaleHe/Him She/Her They/Them (other) _____ / _____

SSN:Date of Birth:

Home Phone:Cell Phone:

Preferred Pronouns:Asian BlackPacific Islander

HispanicWhite

Native American

Single (never married) Married (or in a Domestic Partnership)(other) ___________

Widowed Divorced Separated

Race:

Marital Status:

Gender/Age of Children:Religious Preference:

Emergency Contact Name:E.C. Cell Phone:Street Address:

City:State:

Known Allergies:

Gender:

____________________________________________________________

Citizen/Immigration Status:

____________________________________________________________________________________________________

__________________________________________________________________________________________________________ Zip: _____________

DSM V and ICD Codes:________________________________________________

Date of IPU Admission________________________

Criminal Record / Legal Status:________________________________________________

*Must be a resident of the county for which you are applying and have a primary diagnosis of a major psychiatric disorder.

PROGRAM-SPECIFIC INFORMATION* (Indicate all that apply in desired program)

Partial Care:

Homeless Outreach:


Behavioral Health ServicesBridgeway

Employment ServicesStabilization / Structure

Independent Living SkillsMental Health Education

SocializationSupportive Counseling

MICA Services

Homeless Single Adult Referral and LinkageAt Risk of Homelessness Parent with Children

Supportive Housing:Individual wants permanent affordable housing.Individual wants to live independently with supports.Individual is living in a residential program and is ready to graduate to independent living.Individual is capable of taking care of some basic living skills but needs some support in some areas.Individual has some insight into his/her mental illness and is motivated to work on independent living goals.

PACT Team Services:Serious & persistent mental illness of at least 12 months in duration.Demonstrated lack of benefit from refusal to participate in intensive ambulatory or residential mental health services for a duration of at least six months.

Two or more State HospitalizationsOne State Hospitalization with one or more other psychiatric hospitalizationsOne State Hospitalization with multiple screening center episodesTwo or more STCF and/or County Hospital admissionsOne STCF or County Hospital Admission with one or more other psychiatric hospital admissions/or multiple screening center episodesTwo or more involuntary psychiatric hospital admissions at private psychiatric hospital

Hospitalization history within past 18 months (must meet one of the following):

IPU Dates and Names of hospitals for past 18 months (must complete for PACT admission):____________________________________________________________________________________________________________________________________________

PRESENTING PROBLEMS (Check all that apply)

Alcohol AbuseAnxietyAssaultive Behavior / ThreatBizarre BehaviorDaily Living ProblemsDepression / Mood DisorderDestructive to PropertyDevelopmental DisabilityDrug Abuse

Eating DisorderEconomic StressFire Setting / IdeationHomicidal Behavior / ThreatLegal / Justice InvolvementMarital / Family ProblemsMedical / Somatic ConcernsNo Social Support ResourcesOrganic Mental Disorder

Physical NeglectRunaway BehaviorSexual Abuse / Rape VictimSexual AbuserSocial / InterpersonalSuicide AttemptSuicide ThreatThought DisorderOther: ___________________

REFERRAL FOR:

PACT and Supportive Housing referrals may skip this section and proceed to the Current Medication section.

COMMUNITY TREATMENT PLAN (for Partial Care and/or Homeless Outreach only)


Behavioral Health ServicesBridgeway

Medical Treatment Plan: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Psychiatrist Name:Phone:


State:Next Appointment:

____________________________________________________________________________________ Zip: ______________________________

Service Provider Name:Phone:


State:Next Appointment:

____________________________________________________________________________________ Zip: ______________________________

Complete this section ONLY IF no psychiatric or medical records accompany the referral.

PSYCHIATRIC BACKGROUND INFORMATION

CURRENT MEDICATIONS (for all referrals)

Medication: Dosage: Frequency:_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Psychiatric History:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Precipitating Factors for most recent Hospitalization:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

REFERRAL FOR:

REFERRAL FOR:


Behavioral Health ServicesBridgewayPSYCHIATRIC BACKGROUND INFORMATION (Continued)

Physical / Medical Conditions: (Please include date of last physical and fax documentation)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Substance Abuse History / Treatment:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Comments: (Please include a brief description of any other relevant concerns)

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ACCEPTED DATE STARTED: ______________NOT ACCEPTED

REASON FOR DENIED ACCEPTANCE:

REFERRED TO: _________________________________________________________

Does not meet eligibility criteria

Refused program

Other: ____________________________

Lost

Substance Abuse only

Long term Hospitalization

FOR INTERNAL USE ONLY

Elizabeth PACT 1Plainfield PACT 2Union PACT 3Hunterdon/Warren PACT 4Hudson PACT 5

(973) 860-5147(908) 791-0512(908) 688-5377(908) 835-8650(201) 653-5049

Somerset PACT 6Passaic PACT 7Passaic PACT 8Bergen PACT 9Essex PACT 10 -13

(908) 595-1921(973) 638-1126(973) 638-1119(201) 880-8326(973) 241-1366

Essex/Hudson RIST 5 Homeless Outreach PATH UnionSupportive Housing Hunterdon Supportive Housing / ISH UnionPartial Care Union

(973) 860-5166(973) 860-5166(908) 894-5309(973) 860-5166(908) 355-8853

Please fax this (and any specified attachments) to the appropriate County/Program’s fax number listed below.

END OF REFERRAL FORM

bridgeway pc / ho / sh / pact referral form

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