Components of a community referral form

1. Referral source information: Name, contact information, organization, and role of the person making the referral.

2. Client information: Name, contact information, age, gender, and any relevant demographic information.

3. Reason for referral: Brief description of the client's needs or concerns that warrant a referral.

4. Referral details: Specific services or resources being requested, including any preferences or requirements.

5. Client consent: Confirmation that the client has given consent for the referral to be made and for their information to be shared with the referral agency.

6. Referral agency information: Name, contact information, services offered, and any other relevant details about the agency being referred to.

7. Follow-up plan: Proposed timeline for follow-up communication or next steps after the referral has been made.

8. Additional notes or comments: Any other relevant information or considerations that may be important for the referral process.

1. Patient Information
- Name
- Date of birth
- Gender
- Address
- Phone number
- Email address

2. Reason for Referral
- Brief description of the patient's symptoms or concerns
- Medical history
- Current medications
- Previous treatments

3. Requested Services
- Specific services or programs that the patient is being referred to
- Expected duration of services

4. Referring Provider Information
- Name
- Profession
- Address
- Phone number
- Email address

5. Receiving Provider Information
- Name
- Profession
- Address
- Phone number
- Email address

6. Insurance Information
- Primary insurance carrier
- Policy number
- Group number
- Secondary insurance carrier (if applicable)
- Policy number (if applicable)
- Group number (if applicable)

7. Authorization for Release of Information
- Patient's signature authorizing the release of medical information to the receiving provider
- Date of signature

8. Other Information
- Any additional information that may be helpful to the receiving provider, such as:
- Patient's goals
- Patient's preferences
- Patient's support system
- Previous interventions that have been tried and their outcomes