TGH Behavioral Health Hub Referral Form
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Guardian/Parent Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Last Four of Patient's Social Security if available
MRN if Applicable
Referring Provider Information
Referring Provider's Name
*
First Name
Last Name
Phone Number
*
Optional
Format: (000) 000-0000.
Name and preferred contact information for the individual who should receive consult summaries and ongoing updates, if different from the referring provider:
Behavioral health symptoms impacting functioning (psychiatry input requested for diagnostic clarification, treatment guidance, medication options, etc.):
*
Please enter any questions or comments you may have.
Please check the service requested: (Check all that apply)
*
Care Coordination combined with consultation or evaluation
Care Coordination only
Consultation with a Psychiatrist (Doc to Doc consult)
Asynchronous consultation support when appropriate
Psychiatric Eval with family, followed by a consultation with the provider.
Comments:
In addition to the referral form, supplemental documentation is required to complete the patient intake process. Please either attach the completed documents below or submit them via email to BehavioralHealthHub@tgh.org or fax to 813-844-6905.Additional required documents can be accessed at https://www.tgh.org/TGHBHHubReferral
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