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ROI - Guardian Pharmacy
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IRTS REFERRAL INFORMATION FORM
"
*
" indicates required fields
Contact Information
Today's Date
MM slash DD slash YYYY
Gender
Male
Female
Non-Binary
Genderqueer or Genderfluid
Other
Client Name
*
First
Last
SS#
MA#
DOB
*
MM slash DD slash YYYY
Client Current Location
Client Phone
Case Manager (if different)
Phone
Case Manager (if different)
Phone
Psychiatric Care Provider
Phone
Anticipated discharge from Hospital
MM slash DD slash YYYY
Preferred Date for IRTS Admission
MM slash DD slash YYYY
Diagnoses
Please Describe
Type of Commit
MI
MI/CD
CD
MI&D
Any current prescription sent over to our providing pharmacy with a 30-day supply
No
Yes
If YES, please list prescriptions
Benefits
County of Financial Responsibility
Monthly Gross Income:
Income Source(s):
GA
SSI
RSDI
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Benefits Type
MA Open
MA Pending
SMRT Pending
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THE FOLLOWING INFORMATION WILL BE REQUIRED PRIOR TO INTAKE:
Please Select Completed Items
Current Scripts for all medications with a 30 day supply and arrangements for the ability to refill.
If referent is on a stay of commitment or full commitment, a copy of the court findings which indicate the type of commitment/Jarvis as well as a copy of the provisional discharge.
Copy of Standing orders completed and signed by a medical provider. (SEE Provider’s FORM)
Completion of the following page to include goals while in placement and cultural and other considerations.
Select All
Mental Health Goal 1
Mental Health Goal 2
Mental Health Goal 3
Mental Health Goal 4
ADDITIONAL INFORMATION PERTINENT TO IRTS PLACEMENT
Please include support system, cultural considerations, etc.
Please Describe
Digital Signature
Please type Client name or Legal Guardian/Authorized Person here.
Today's Date
MM slash DD slash YYYY
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Email
This field is for validation purposes and should be left unchanged.
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