Day Hospital Referral Form

The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit North American phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

uGuLCHxCVLG5nzNAuWBR6WjBLYce5vX8VYVN3wKXgDU9uRaeb5jfb5ZtwU9KHIxqAMAtf4nz3upXs7a

Big news - enrolling in a Sheppard Pratt day hospital is easier than ever! We've updated our process so patients can access care faster.

What has changed?

We are now accepting referrals over the phone. Patients or their parent/guardian will complete a brief screening and be informed immediately if they are eligible for the Day Hospital level of care.

Clinical notes are no longer required for referrals and admissions.

Patients do not need to complete a screen at Psychiatric Urgent Care before admitting.

If a patient is on an inpatient unit, we will complete a screen with the referring provider/discharge coordinator.

If you would like to have a patient call us directly about admission, we can be reached at 410-938-4949 (choose option 1), Monday - Friday, 7:30 a.m. - 4:00 p.m.

If you are reaching out during non-business hours, you can submit the following form, and we will reach out by the next business day.

Referral FormPDF

Upload file

Referring from:

* must provide value

Sheppard Pratt

Other Referring Entity

reset

Referring Provider

* must provide value

Medical Record Number

* must provide value

Sheppard Pratt staff contact name.

* must provide value

Sheppard Pratt staff contact phone number.

* must provide value

Referral Type

* must provide value

PUC

Stepdown from Inpatient

Sheppard Pratt Outpatient

Residential/ Crisis Bed

reset

What unit is the patient on?

* must provide value

Discharge Date

* must provide value

Outpatient Program

* must provide value

Community OMHC

Hospital Based OMHC

reset

Residential/ Crisis Setting

* must provide value

Setting: Other Referring Organization

* must provide value

Inpatient

Outpatient

Residential Treatment Center

reset

ED Referring Entity

* must provide value

Other ED Name

* must provide value

Inpatient referring entity

* must provide value

Outpatient referring entity

* must provide value

RTC referring entity

* must provide value

Referral Contact Name

* must provide value

Referral Contact Phone Number

* must provide value

Patient First Name

* must provide value

Patient Last Name

* must provide value

Patient Sex (for Verification)

* must provide value

Male

Female

reset

Patient's Preferred Name and Pronouns (if applicable)

Patient DOB

* must provide value

M-D-Y

Parent/Guardian Name (Required for Child & Adolescent Referrals or Adults with Legal Guardians).

Patient or Guardian Phone Number (Please verify with Patient and/or Guardian)

* must provide value

Email Address (Please verify with Patient and/or Guardian)

* must provide value

Home Address (Please verify with Patient and/or Guardian)

* must provide value

Does the patient have a current diagnosis of psychosis, or schizophrenia/ schizoaffective disorder?

* must provide value

Yes

reset

Insurance Type **Please note: We are unable to accept Tricare and out of state medical assistance**

* must provide value

Maryland Medicaid

Medicare

Other

reset

Patient and/or Guardian needs an interpreter (If yes, please note the language needed below)

* must provide value

Yes

No interpreter is required

reset

Language needed-

* must provide value

Please choose the Day Hospital program and location.

* must provide value

Adult Day Hospital

Child and Adolescent Day Hospital (age range: 10 - 17)

reset

Preferred Location **Please note: the Day Hospital admissions team will determine which program/location the patient will be assigned to based on a variety of factors**

* must provide value

Towson Campus (10-17)

Baltimore Washington Campus (12-17)

reset

Additional Comments or Information

Expand

Clinical File Upload

Upload file

Clinical File Upload 2

Upload file

Clinical File Upload 3

Upload file

Clinical File Upload 4

Upload file

Clinical File Upload 5

Upload file

Clinical File Upload 6

Upload file

Clinical File Upload 7

Upload file

Clinical File Upload 8

Upload file

Clinical File Upload 9

Upload file

Clinical File Upload 10

Upload file

Patient_last_initial

View equation

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.