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Required format:

HZoDjapE5j52PtAEAYXuccarxEtE6uszMaAFSDe8HfRdLMWZxLGK8qcsZHFIkisI4eYVo

Day Hospital Referral Form

Welcome! Before making this referral, please validate:

Patient is aware they are expected to attend programming for at least 2 uninterrupted weeks (up to 6 weeks depending on program) from 8:00am - 3:00pm Monday through Friday.

Patient is able to tolerate a full day of treatment (6.5 hours of sitting in groups) and independently access services.

Patient has transportation to and from programming Monday through Friday (if not, patient is aware they may not be able to attend).

Patient is aware this is a group-based program. Individual therapy is NOT a component of programming. A Nurse Practitioner or Psychiatrist will be assigned for medication management.

PLEASE NOTE, you will be asked to upload the following documentation at the end of this form if you are NOT referring from Sheppard Pratt's Psychiatric Urgent Care or Sheppard Pratt Inpatient:
- - Psychiatric/Psychosocial Admission
  - Last 3 Clinical Notes
  - Medication List
  - Photo ID
  - Insurance Card (Both Sides)
Thank you, and please call our admissions coordinators 410-938-4949 if you need assistance!

Referral FormPDF

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Referring from:

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Sheppard Pratt

Other Referring Entity

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Referring Provider

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Medical Record Number

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Sheppard Pratt staff contact name.

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Sheppard Pratt staff contact phone number.

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Referral Type

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PUC

Stepdown from Inpatient

Sheppard Pratt Outpatient

Residential/ Crisis Bed

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What unit is the patient on?

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Discharge Date

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Outpatient Program

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Community OMHC

Hospital Based OMHC

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Residential/ Crisis Setting

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Setting: Other Referring Organization

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Inpatient

Outpatient

Residential Treatment Center

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ED Referring Entity

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Other ED Name

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Inpatient referring entity

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Outpatient referring entity

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RTC referring entity

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Referral Contact Name

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Referral Contact Phone Number

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Patient First Name

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Patient Last Name

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Patient Sex (for Verification)

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Male

Female

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Patient's Preferred Name and Pronouns (if applicable)

Patient DOB

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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)

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

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

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

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Yes

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

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Maryland Medicaid

Medicare

Other

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

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Yes

No interpreter is required

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Language needed-

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Please choose the Day Hospital program and location.

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Adult Day Hospital

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

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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**

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Towson Campus (10-17)

Baltimore Washington Campus (12-17)

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