Referral Form and Certification of need for services

Referral for services

"*" indicates required fields

Referring Provider*

Client Name*

Email*

Age/DOB*

Gender*

Male

Female

Telephone*

Insurance Carrier

Parent or Legal Guardian

Mailing Address

Telephone

Please list previous Behavioral Health and Substance Use Treatment providers.

Provider

Level of Care

Admit / Discharge Date

Outcome of Episode

A complete Referral Packet must include the following to be processed:

Referral Form

Certificate of Need signed by MD (see next page)

Records from most recent hospital admission

Records from previous psychiatric, mental health or substance use providers supporting the need for services must be current. (within 30 days)

Release of Information for parent or primary guardian

This referral, Certificate of Need (CON), and records may be faxed to our Admission Department
Fax: (503) 746-5906
Email: admissions@madronarecovery.com

Upon screening of a complete Referral Packet our admission counselors will schedule an inquiry phone screening with primary guardian. Youth are encouraged to participate whenever possible.

Certificate of Need (To be completed by MD, preferably Child Psychiatrist)

1) Ambulatory care resources available in the community do not meet treatment needs of the beneficiary
2) Proper treatment of the beneficiary’s psychiatric condition requires services on an inpatient basis under the direction of a physician; and
3) The services can reasonably be expected to improve the beneficiary’s condition or prevent further regression so that the services will no longer be needed.

Narrative

By signing below, you certify that the individual being referred for Madrona Recovery PRTF services meets all 3 of the following criteria.

Full Name of Referring Physician

Signature

Date

Certification must be made by an independent team that includes a physician who has knowledge of the youth’s situation and is competent to diagnose and treat mental illness, preferably a child psychiatrist.

Referral Form and Certification of need for services

Referral for services

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