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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 Page 1 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:
Bridgeway Behavioral Health Services PC/HO/SH/PACT General Referral Form - Fillable PDF - Last Revised 07/29/2021 Page 2 of 4
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)
Bridgeway Behavioral Health Services PC/HO/SH/PACT General Referral Form - Fillable PDF - Last Revised 07/29/2021 Page 3 of 4
Behavioral Health ServicesBridgeway
Medical Treatment Plan: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
Psychiatrist Name:Phone:
Street Address:City:
State:Next Appointment:
____________________________________________________________________________________ Zip: ______________________________
Service Provider Name:Phone:
Street Address:City:
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:
Bridgeway Behavioral Health Services PC/HO/SH/PACT General Referral Form - Fillable PDF - Last Revised 07/29/2021 Page 4 of 4
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