Behavioral Health Referral Form Template
Connect clients to behavioral health services with a structured referral that gives receiving providers the clinical context they need — before the first appointment.
Behavioral health referrals are most effective when the receiving provider has enough context to prepare. A structured referral form captures the presenting concerns, relevant history, current medications, risk factors, and the reason for referral in a format that integrates into intake workflows — eliminating the delay and information loss that comes with verbal or informal referrals.
This template covers the referring provider's details, client name and demographics, presenting behavioral health concerns, relevant psychiatric and medical history, substance use history, current medications, risk assessment summary (suicidality, self-harm, aggression), the type of behavioral health service being sought, urgency level, consent for information sharing, and the referring clinician's signature.
Primary care providers, emergency departments, school counselors, substance use programs, and community health workers use behavioral health referral forms to connect clients with mental health, substance use, and integrated care services. Route urgent referrals immediately. Track referral-to-appointment conversion rates to identify gaps in the referral pathway.
Behavioral health referrals are typically broader — covering mental health, substance use, and integrated care. This form includes substance use history fields that may not appear in a mental health-specific referral.
Add an urgency field and configure high-urgency submissions to trigger an immediate phone call or Slack notification to the receiving team.
Build a follow-up step into your workflow. Contact the receiving provider or client at 30 days post-referral to confirm connection and close the loop.
Yes — include a consent to share information field. The client's authorization is required before clinical information is shared between providers in most cases.
Add a 'warm handoff requested' field. When selected, trigger a workflow that schedules a direct call between the referring and receiving provider to introduce the client.
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