BEHAVIORAL HEALTH PARTIAL PROGRAM

Thank you for your interest in the Behavioral Health Partial Program.

The partial hospital program is comprehensive treatment that is provided for six and a half hours per day. You are expected to start your first day at 8:00 am to give time for program orientation, and then on your second day attend the regular hours of 8:30 am to 3 pm, Monday-Friday.

Please ask your outpatient provider to complete the referral form and fax it back to the Intake Coordinator, Debbie Flynn, at 617.855.3723. The Behavioral Health Partial Program works with patients who use substances (e.g., alcohol, marijuana, and other drugs). Please review the Substance Use Agreement form with your outpatient provider and fax the signed form back with your referral form.

Note to outpatient providers: Please provide current detailed clinical information by filling out the referral form, in order for us to determine that your patient meets partial level of care. Most insurance companies consider partial hospital level of care to be a brief (one to two weeks) intensive treatment in lieu of inpatient hospitalization.

For further questions regarding the program, please call us at 617.855.3286.

BEHAVIORAL HEALTH PARTIAL PROGRAM

BHP Community Referral Form Date of Referral:_______________________ Name: _______________________________ DOB: _____________ Requested Start Date: ___________ Address: ____________________________ City: _____________________ State:_____ Zip: _________ Phone #: __________________ Cell Phone #: _________________ Email: _________________________ Occupation: ___________________________________________________________________________ Referred By: __________________________________________ Phone #: _________________________ Primary Insurance: ______________________________________________________________________ ID #: __________________________________________ Phone #: (to verify benefits) ___________________________

Subscriber: ________________________________________ Subscriber DOB:_____________________ Secondary Insurance: ___________________________________________________________________ ID #: __________________________________________ Phone #: (to verify benefits) ___________________________

Subscriber: ________________________________________ Subscriber DOB:_____________________Psychiatric Diagnoses: ___________________________________________________________________ ______________________________________________________________________________________ Medical Diagnoses (include any needed accommodations): _____________________________________________ _____________________________________________________________________________________ Why does the patient currently need a higher level of care?: __________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Goals for Behavioral Health Partial: _______________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Current Living Situation: _________________________________________________________________ Able to commute to program by: Car Public Transportation Other____________________

# of Psychiatric hospitalizations in the past 2 years & facility: ______________________________ # of Detox hospitalizations in the past 2 years & facility: _______________________________

History of Substance Abuse: Drug

(check) Amount Frequency Date of Last Use

Alcohol Benzodiazepines

Heroin Opiates

Marijuana Stimulants

Other *Patient is willing to maintain sobriety from all substances and sign Substance Use Agreement recommendations: Yes NoLongest period of sobriety & when: __________________________________________________________ History of Eating Disorder: Yes No If yes, active symptoms: ___________________________ Current Height: ____________________ Current Weight: __________________ Revised 02/17/2017

Current Medication & Dosages: Is patient medication adherent? Yes No______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________

Allergies: _____________________________________________________________________________________

Current Outpatient Treatment Team: Psychiatrist/Medication Prescriber: _______________________ Phone#__________________ Frequency:________________

Therapist: _______________________ Phone#__________________ Frequency:________________ PCP: ______________________ Phone#__________________ Frequency:________________

Other: ______________________ Phone#__________________ Frequency:________________

History of Suicide Attempt(s): Yes No specify dates & means: ___________________________________ _____________________________________________________________________________________________________

History of Self-Injurious Behavior: Yes No specify frequency, means & last occurrence: ________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

Access to Firearms or Weapons? Yes No *if yes, specify type and where located:___ ________________ _____________________________________________________________________________________________________

History of Trauma: _____________________________________________________________________

Current Safety Status: Self:__________________________ Other:______________________

Legal Status Probation: Yes No Court Date: Yes No Charges Pending: Yes No Restraining Order: Yes No

Forward copies of the following information: Initial Assessment History/Physical Psych Testing (if available)

_____________________________________ ____________________________________ Clinician Signature Name

*Fax completed form to Debbie Flynn, Intake & Referral Coordinator, at 617.855.3723

Revised 02/17/2017

Revised 09/19/2016

BEHAVIORAL HEALTH PARTIAL PROGRAM

Substance Use Agreement

The Behavioral Health Partial Program works with patients who use substances (e.g., alcohol, marijuana, and other drugs). We want to help you maintain your sobriety while in the program and expect patients to agree to the following treatment recommendations:

• To participate in substance use groups if requested by staff.

• To abstain from using any alcohol or drugs, other than those prescribed as directed by yourpsychopharmacologist.

• To provide a random alcohol/drug screen (urine specimen or breathalyzer) if requested by staff.

• To report any substance use to my treatment team.

These expectations were reviewed with me and I agree to follow them while I am in the Behavioral Health Partial Program.

___________________________________________ _____________________ Patient's Signature Date

___________________________________________ Print Name