St. Luke’s / Roosevelt Hospital Center

Department of Psychiatry PLEASE DELIVER TO: ________________________________

Intake Coordinator: Andrea Johnson, LCSW

Telephone #: 212.523.7693 FAX #: ________________________________

Fax #: 212.523.2140

Women’s Health Project Referral Form

REFERRER CONTACT INFORMATION:

Referral Source (Agency / Dept. / Org.): ___________________________________ Date: __________________

Referral Contact Person: ____________________________ Contact Number (s): _______________________________

PATIENT’S CONTACT INFORMATION:

Name Of Individual Being Referred: ____________________________________________________________________

Date Of Birth: _______________________________ Social Security #: ______________________________

Home Address: _____________________________________________________________ Apt. #: _____________

City / State: ____________________________________________ Zip Code: ______________________________

Home Phone #: _________________ Work Phone #: __________________ Mobile Phone #: __________________

Emergency Contact Name: _________________________________ Telephone #: ______________________________

OUTPATIENT MENTAL HEALTH INSURANCE INFORMATION:

Please Note: This Information Is Critical and Must Be Provided By the Referring Agent.

Insurance Company Name: _________________________ Insurance ID # (s): _________________________________

Insurance Pre-Authorization Code(s): __________________ Insurance Company Telephone #: ____________________

PATIENT INFORMATION:

Can Patient Communicate Effectively In English?: Yes No If Not, Primary Language Is: _______________________

Is this a “COPS” Referral?: Yes No Patient’s Marital Status: ________________________________

Reason For Referral: _______________________________________________________________________________

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Is Patient Specifically Interested in the Women’s Health Project?: ____________________________________________

Psychiatric Diagnosis: _______________________________________________________________________________

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Medical Diagnosis: _________________________________________________________________________________

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Does the Patient Present With Current Suicidal Ideation? Yes No If Yes, Is The Ideation: Active Passive

Explain Briefly: ____________________________________________________________________________________

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Does the Patient Present With Current Homicidal Ideation: Yes No If Yes, Is The Ideation: Active Passive

Explain Briefly: ____________________________________________________________________________________

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Please List Current Medications: ______________________________________________________________________

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Current Use of Alcohol And / Or Substances: ____________________________________________________________

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Has Referral Been Discussed With The Patient? Yes No Has Patient Accepted This Referral? Yes No