For Referring Providers

IOP / PHP Clinical Referral

Secure pathway for clinicians referring into partial hospitalization or intensive outpatient. Acknowledged within one business day; clinical review and patient outreach within two.

✓The full clinical packet — demographics, clinical picture, medications, care team — submits right here

✓Prefer fax? (207) 747-4067 (IOP/PHP)

✓Case questions: (888) 280-2585 — identify as a referring provider

Referral details

This form accepts the full clinical referral packet directly — it travels a secure, HIPAA-covered pathway to our intake team. All clinical fields are optional; share what you have. Prefer fax? The full packet can also go to (207) 747-4067.

Patient

Patient name *

Best contact # *

Pronouns

Patient date of birth

Patient address

Insurance

Patient insurance carrier

Insurance ID # (optional)

Group # (optional)

Subscriber name (if not the patient)

Number to verify benefits

Referring provider

Referring provider *

Practice / organization *

Provider phone *

Provider fax

Credentials

Length of treatment relationship

Date of referral

Date of most recent visit

Program requested

Clinical picture

Current symptoms, functional impairment, and why needs are best met at this level of care

Recent safety concerns (non-suicidal self-injury, suicide behaviors or attempts, risk-taking, inability to care for self, aggression or threats to others)

Primary goal

Secondary goal

Has the patient agreed to participate if accepted?

Yes No

Is substance use an active concern?

Yes No

Is an eating disorder an active concern?

Yes No

Previous mental health treatment programs (hospitalizations, PHP/IOP, outpatient, substance use treatment)

What treatment alternatives to IOP/PHP have been or are being considered?

Medications & history

Alcohol use

Tobacco use

Caffeine use

Drug use

Current medications (name, dose and frequency)

Medication allergies and adverse reactions

Medication adjustments or changes deemed necessary

Is the patient compliant with medications?

Yes No

Past medical history

Any other pertinent social or trauma information

Care team

Psychiatrist

Therapist

Dietician

Primary care

Other

Anticipated prescriber at discharge

If the patient has no current outpatient prescriber, list all referrals made (including status)

Comments / other relevant information

Encrypted in transit · HIPAA-covered pathway · not for emergencies

IOP / PHP Clinical Referral

Referral received.

Referral details

Patient

Insurance

Referring provider

Clinical picture

Medications & history

Care team