External Provider Referral Form

Patient Information

Phone

Client Demographics

Primary Language*

What is your primary language?:

Check the boxes that most accurately describe your ethnic origin:

Check the boxes that most accurately describe your race:

I am referring this patient for services in the following Retreat program(s):

NOTE:

All Inpatient referrals must be sent by Crisis Services and/or an Emergency Department. Please call 802-258-3700 for more details.

For TMS, please complete the TMS specific referral form.

For Esketamine, please complete the Specialty Medication Clinic specific referral form.

Select
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Presenting Problem(s)

Briefly describe the patient's presenting problem(s) and most recent helpful intervention(s):

Is this recent?*
Does the patient have access to technology (computer, internet service, etc.) that would allow participation in a remote treatment program using Zoom?*
Does the patient have access to a private space for the duration of a session or group therapy?*

As a note, for PHP, the requirement is for 5 hours of continuous, confidential, private space.

Is the patient currently on an Inpatient unit?*

Please list current diagnoses below:

Insurance

Phone
Subscriber's Relationship

Referring Provider Information

Phone

Substance Use

Is the patient using tobacco, alcohol or illicit drugs?*

Please list the Drug of Choice, Age of first use, Last use, Amount of use and any comments needed.

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Opiods/Opiates (MAT)*
Alcohol Use (MAT)*

Functionality

Check all that apply

Do any of the following relate to the patient's current life situation?

If yes, please check the appropriate box beside each category:

Employment
Adult Education
Child Education
Child Care
Parenting Skills

Optional SELF-SUFFICIENTY MATRIX

The following self-assessment tool is for individuals who wish to determine their own strengths and areas for improvement. (Completed by client/patient or with provider).

Does the patient wish to complete the SELF-SUFFICIENCY MATRIX?*
Food
Housing
Income
Personal Safety
Transportation
Ability to Function
Criminal Justice System
Legal System (non-criminal)
Money/Finances
Support System
Substance Usage
Physical Health
Mental Health
Employment

NOTE:

To fully process this referral, please upload or fax a copy of:

1.) the most recent medical note

2.) medication history and

3.) the front and back of the individual's insurance card.


Fax: 802-258-3788

Will you be faxing or uploading these documents?*

If the requested documents are not received, the referral cannot be fully processed and will result in a delay. If you are faxing these documents, please indicate so. Thank you.

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