EmailMeForm
Facility Based Crisis Referral
Date of referral
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Date available for admission
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MM
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DD
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What is the best email address for contacting you?
What is the best phone number for contacting you?
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Is this referral for you or someone else?
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Self
Someone else
Patient's Information
Please provide the following information for patient.
Patient's full name
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First
Last
Patient's preferred name (if applicable)
Patient's date of birth
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DD
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YYYY
Patient's gender identify
Patient's sex
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Male
Female
Patient's social security number
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Patient's phone number
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Patient's email address
Patient's address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Reason for referral and presenting problem
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General statement about challenges the patient is experiencing with family, school, home or legal
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Substances used/misused by the patient
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Alcohol
Benzodiazepines
Fentanyl
Marijuana
Meth
Mushrooms
Opioids
Over-the-Counter medications
Tobacco/Vape/Smokeless Tobacco/ Cigarettes
Diagnosis
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Other
Other Substances Used/Misused
Past hospitalizations and recent treatment history.
Please include both inpatient, outpatient, community based and reason for referral to level of care.
#1
Place and date of service
Type of service
Reason for admission
Comments Regarding completion and/or effectiveness
#2
Place and date of service
Type of service
Reason for admission
Comments Regarding completion and/or effectiveness
#3
Place and date of service
Type of service
Reason for admission
Comments Regarding completion and/or effectiveness
#4
Place and date of service
Type of service
Reason for admission
Comments Regarding completion and/or effectiveness
#5
Place and date of service
Type of service
Reason for admission
Comments Regarding completion and/or effectiveness
Please list any medical conditions. allergies or current medication taken by the patient
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PLEASE NOTE: A minimum 7-day supply of medications must be provided by the patient at the time of admission or the patient may not be admitted to the program.
Legal History
Patient is on probation
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Yes
No
Name of Probation Officer
Contact number for Probation Officer
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Current pending charges
Court dates that will occur while patient is in treatment with Easterseals PORT Health
Referral Information
Contact information of referring agency.
Referring agency's contact name
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Referring agency's phone number
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Referring agency's address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Referring agency's email
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Insurance Information
Copy of insurance card must be presented at time of screening, however you may attach a copy to the referral form as well.
Patient's insurance provider
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Patient's insurance policy number
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Do you have a preferred facility location?
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Ahoskie, NC
Greenville, NC
Jacksonville, NC
No preference for facility location
Washington, NC
Documents to Upload
Add File
Signature of Referring Person
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Clear
