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5tUoqJQVpIKwiGEyQU2JvhByUJC3mPKVWUkat

University of Washington Medical Center Behavioral Health Referral

Returning?

A A A

We appreciate your commitment to completing the University of Washington Medical Center (UWMC) Behavioral Health Referral Form. This form is designed for Referring Providers or Patients who are self-referring to be assessed for treatment in one of our Adult (18 years or older) programs.

To ensure accuracy and efficiency, kindly follow the instructions below:
1. Fill out all required fields marked with an asterisk (*).
2. Provide detailed and accurate information.
3. If a section is not applicable, mark it accordingly or write "N/A."

Questions? Please call 206-668-5470.

Referrals must be entered by the patient or provider. Referrals by family members or friends are not reviewed. UW Medicine providers may use the internal referral order to all services within Epic.

Service Descriptions

Only providers can refer patients transferring from other medical facilities for the following two services:

Long-Term Civil Commitment: inpatient psychiatric care for patients mandated by a court process for civil commitment stays of 90 to 180 days.
Geriatric Psychiatry: inpatient psychiatric care for patients 60 years or older experiencing acute behavioral health concerns.

Providers and patients can refer to the following services:

If referring for Neuromodulation (TMS & ECT), please ensure the patient has a provider that they routinely see for psychiatry follow-up care.

Transcranial Magnetic Stimulation (TMS): a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression.
Electroconvulsive Therapy (ECT): a procedure, done under general anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure to reverse symptoms of certain behavioral health conditions.
Intensive Outpatient Program (IOP): a structured intensive outpatient treatment for individuals who require more than traditional outpatient therapy but do not need 24/7 supervision. Provides multiple group therapy sessions per week, allowing patients to continue their daily routines while receiving crucial support.

Service Referral Type (select all that apply)

* must provide value

Long-Term Civil Commitment

Geriatric Psychiatry

Transcranial Magnetic Stimulation (TMS)

Electroconvulsive Therapy (ECT)

Intensive Outpatient Program (IOP)

Reason for referral (select all that apply)

* must provide value

Anxiety

Chronic Pain

Dementia with behavioral disturbances

Depression

Obsessive Compulsive Disorder

Psychosis

Self Harm

Other

Other referral reason

Who is completing this referral?

* must provide value

Patient (self)

Provider

Social Work

Family Member/Friend

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Social Worker Name

* must provide value

Social Worker Phone number

* must provide value

Referring Facility Name

* must provide value

Referrals must be entered by the Patient or Provider. Referrals by family members or friends are not reviewed.

Is this referral for a Voluntary or ITA admission?

Voluntary

ITA

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Patient Full Name

* must provide value

Patient Date of Birth

* must provide value

M-D-Y

Patient Address

* must provide value

Patient Phone

* must provide value

Patient Email

Insurance Provider/Name

* must provide value

Insurance Number

* must provide value

Primary Contact Name

Primary Contact phone number

Primary Contact Relationship

Current Living Situation

* must provide value

Home Alone

Home with Child

Home with Spouse/Relative

Unhoused

Adult Family Home

Assisted Living

Nursing Home

Memory Care

Inpatient Setting

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Please provide the Facility Name (for inpatient referrals, provide Hospital Name):

* must provide value

Medical History (select all that apply)

* must provide value

Alcohol Use

Allergies

Cancer

Cardiac / Circulatory

Dental Problems

Diabetes

Dialysis

Endocrine

Fall history

Gastrointestinal

Labs

Neurological: Dementia, Alzheimer's,

Recreational Drug Use

Respiratory

Sensory

Skeletal

Skin

Tobacco Use

Urinary

Other

Other Medical History, please specify:

* must provide value

Behavioral Health History/Diagnosis

* must provide value

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Current Medications

* must provide value

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Previous Behavioral Health medications tried

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Primary Care Provider (name)?

Behavioral Health Prescriber (name)? (if different than Primary Care Provider)

* must provide value

Referring Provider Full Name

Referring Provider Credential(s) (select all that apply)

ARNP

RN Case Manager

MSW

MH Provider

Other

Other Referring Provider (please specify)

Referring Provider Phone

Provider FAX number

Referring Provider Email

Referring Provider Address

How did you hear about us? (select all that apply)

Google/Search Engine

UW Medicine website

Email Newsletters

Patient

Doctor

Friend/Relative

Event

Social Media

Other

If Other, please specify:

Kindly include legal documents, the latest provider note, a list of medications, and any additional pertinent clinical information

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