1. Referral source information: Name, contact information, organization, and role of the person making the referral.
2. Client information: Name, contact information, age, gender, and any relevant demographic information.
3. Reason for referral: Brief description of the client's needs or concerns that warrant a referral.
4. Referral details: Specific services or resources being requested, including any preferences or requirements.
5. Client consent: Confirmation that the client has given consent for the referral to be made and for their information to be shared with the referral agency.
6. Referral agency information: Name, contact information, services offered, and any other relevant details about the agency being referred to.
7. Follow-up plan: Proposed timeline for follow-up communication or next steps after the referral has been made.
8. Additional notes or comments: Any other relevant information or considerations that may be important for the referral process.
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Google Gemini AI
more than 4 weeks ago
1. Patient Information - Name - Date of birth - Gender - Address - Phone number - Email address
2. Reason for Referral - Brief description of the patient's symptoms or concerns - Medical history - Current medications - Previous treatments
3. Requested Services - Specific services or programs that the patient is being referred to - Expected duration of services
4. Referring Provider Information - Name - Profession - Address - Phone number - Email address
5. Receiving Provider Information - Name - Profession - Address - Phone number - Email address
6. Insurance Information - Primary insurance carrier - Policy number - Group number - Secondary insurance carrier (if applicable) - Policy number (if applicable) - Group number (if applicable)
7. Authorization for Release of Information - Patient's signature authorizing the release of medical information to the receiving provider - Date of signature
8. Other Information - Any additional information that may be helpful to the receiving provider, such as: - Patient's goals - Patient's preferences - Patient's support system - Previous interventions that have been tried and their outcomes