Referral/Request for Services New Patient Form Step 1 of 4 25% New Patient Referral/IntakeReferral Source InformationPlease select one of the options to list where this referral is coming from...* I am an adult seeking services on my own behalf I am an outside organization referring services for an adult I am a Guardian/Parent seeking services for a Dependent/Child I am an outside organization referring a Guardian/Parent for services for a Dependent/Child Organization InformationOrganization Name* Name* First Last Phone*Email (optional) Guardian/Parent InformationThe information gathered for the Guardian/Parent will be whoever is financially and legally responsible for the dependent/child that is being referred for services.Guardian/Parent of Dependent* First Last Guardian/Parent's primary Language* English Spanish Guardian/Parent Date of Birth* Guardian/Parent Social Security Number If you are not comfortable entering your SSN into our HIPAA secure portal, do not worry. You can always provide this to a TEAMCare staff member when you are contacted to schedule.PhoneEmail Enter Email Confirm Email Guardian/Parent Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please specify Guardian/Parent relationship to the patient* Patient Demographic InformationPlease enter the information of the individual that will be receiving services.First Name* Last Name* Suffix Patient Date of Birth* Patient gender* Male Female Unidentified Patient Social Security Number If you are not comfortable entering your SSN into our HIPAA secure portal, do not worry. You can always provide this to a TEAMCare staff member when you are contacted to schedule.Patient's Marital Status* Single Married Widowed Divorced Legal Union Address* Same as previous Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Enter Email Confirm Email Phone*Patients primary Language* English Spanish If "Other" has been chosen for primary language, please specify...* Patient Race* American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White I choose not to answer Patient Ethnicity* Hispanic or Latino Not Hispanic or Latino I choose not to answer Services, Concerns, and InterestsThis section is to understand what services you are looking for, and for us to have everything that we need to provide the services that you are seeking. Which one of our locations do you prefer to receive services?*Lancaster OfficeHarrisburg OfficePlease choose one.Which one of our locations do you prefer to receive services?*Lancaster OfficeHarrisburg OfficeElizabethtown Area School DistrictLampeter-Strasburg School DistrictPenn Manor School DistrictRed Lion Area School DistrictSouthwestern School DistrictLower Dauphin School DistrictPlease choose one.You have selected a school district as your option, we only provide therapy services in the school. What is the name of the child's school building? What grade is the child in? Are you or your child involved in a custody dispute? Custody Evaluations and therapy services with regard to custody or parental fitness are a specialized service that TEAMCare Behavioral Health does not provide. Yes No Are you or your child court referred for mental health services? If so, please be aware TEAMCare Behavioral Health charges fees for any research and preparation related to testifying court proceedings as well as any time spent related to testifying in a court proceeding that are not covered by health insurance. Yes No What services are you seeking?* Therapy Psychiatric Evaluation/Medication Management Comprehensive Testing Psychological Evaluation Parent Child Interaction Therapy (PCIT) Other If other is chosen, please describe...* Please explain your concerns as to why you are looking for services...* Background InformationPlease enter all background information.Do you have a criminal record or any charges pending?* Yes No If yes, please describe...*Any psychiatric hospitalizations in the past 30 days?* Yes No Date admitted* MM slash DD slash YYYY Please enter the date when you were hospitalized.Expected Discharge Date If yes, please tell us where you were hospitalized...* Any thoughts of harming yourself or others in the past 48 hours?* Yes No Mental Health in PA Mental Health in PA offers resources from the Office of Mental Health and Substance Abuse Services (OMHSAS) for mental health and substance use disorder. Get more information on OMHSAS, find Children/Adolescent Resources and Adult/Older Adults Resources. … • National Suicide Prevention Lifeline: 1-800-273-TALK (8255) • LÃnea Nacional de Prevención del Suicidio: 1-888-628-9454 • Crisis Text Line: Text "PA" to 741-741 • Veteran Crisis Line: 1-800-273-TALK (8255) • Disaster Distress Helpline: 1-800-985-5990 CLICK HERE TO BE REDIRECTED TO STATE RESOURCESAny history of substance abuse?* Yes No Any substance abuse in the last 12 months?* Yes No What substance(s) were being used?*When was the last time you used the substance(s) you listed above?* MM slash DD slash YYYY Are you currently in substance abuse treatment?* Yes No Where were you seeking substance abuse treatment?* How long did you attend substance abuse treatment?* Are you currently taking any medications?* Yes No Please be aware that withholding information about prescribed medications does permit TEAMCare the right to withhold/terminate services, and if you are currently prescribed certain controlled substances we may have to refer you to another agency for care.Do you currently take Suboxone or Methadone?* Yes No Since you have indicated that you are currently taking Suboxone or Methadone, unfortunately, we would have to encourage you to contact your insurance to find a facility that specializes in drug and alcohol services. We apologize for any inconvenience.Medications*Medication NameFrequencyAmountPrescribed By Please list your medications above. If you use multiple medications, please click on the "+" to add more lines. If you made an error to remove an item click on "-" Identification & Insurance IMPORTANT PLEASE BE SURE TO KEEP YOUR PICTURE OF JUST THE DOCUMENTS REQUESTED, DO AS MUCH AS POSSIBLE TO NOT HAVE ANY OF THE BACKGROUND VISIBLE. Please upload a copy/image of your Drivers License, State Photo ID, or Passport. Then indicate if you have insurance, if you do we require you to upload a copy/image of your insurance card(s) front and back. If you do not have insurance, we encourage you to follow the link once you have marked "No" to apply for Medical Assistance.Please attach a copy/image of your Drivers License, State Photo ID, or Passport....*Accepted file types: jpg, jpeg, png, gif.If you are a Guardian/Parent of a Dependent/Child, please use your photo ID. IMPORTANT Please make sure that your photo is just of your card and reduce/remove as much of the background when taking your picture as much as possible. Please attach a copy/image of your Drivers License, State Photo ID, or Passport....Accepted file types: jpg, jpeg, png, gif.If you have the ID of the Guardian/Parent of a Dependent/Child, please use the Guardian/Parent photo ID. IMPORTANT Please make sure that your photo is just of the card and reduce/remove as much of the background when uploading the picture as much as possible. Do you have insurance?* Yes No If you have not already done so, we encourage you to apply for Medical Assistance (MA) through the state of Pennsylvania. CLICK HERE TO BE TAKEN TO THE MEDICAL ASSISTANCE APPLICATIONFront of Insurance Card...*Accepted file types: jpg, jpeg, png, gif.Please attach a copy/image of the front of your insurance card. IMPORTANT Please make sure that your photo is just of your card and reduce/remove as much of the background when taking your picture as much as possible. Back of Insurance Card...*Accepted file types: jpg, jpeg, png, gif.Please attach a copy/image of the back of your insurance card. IMPORTANT Please make sure that your photo is just of your card and reduce/remove as much of the background when taking your picture as much as possible. Insurance Name* Insurance Member ID* Do you have a secondary insurance?* Yes No Insurance Name* Insurance Member ID* Front of secondary Insurance Card...*Accepted file types: jpg, jpeg, png, gif.Please attach a copy/image of the front of your secondary insurance card. IMPORTANT Please make sure that your photo is just of your card and reduce/remove as much of the background when taking your picture as much as possible. Back of secondary Insurance Card...*Accepted file types: jpg, jpeg, png, gif.Please attach a copy/image of the back of your secondary insurance card. IMPORTANT Please make sure that your photo is just of your card and reduce/remove as much of the background when taking your picture as much as possible. Δ
