For 24/7 referrals please contact us at - Phone: (225) 663-2881 Fax: (225) 355-1555

November 24, 2017 06:12:33 AM

INQUIRY CALL FORMPrint

Status: Phone Call PEC CEC Info Taken By:
Caller/Referral Source: Phone:
Company/Place calling from:
How did you hear about us?:
Patient Details
Patient name: DOB: Age:
Gender:  M F SS#:  
Race: Marital Status:  S M D W Phone #:
Address:
 Homeless Group Home Alone With others Nursing Home Accept Back:  Yes No
Emergency Contact/Relation to patient: phone#:
Problem (Hx of ): Psychiatric:
Drugs-Last Use: Alcohol-Last Use:
Brief history of the problem:
Medications:
Allergies: Meds obtained from:  Pharmacy MHC Other
 Harm to Self Harm to Others Gravely Disabled Depressed Psychotic Agitated
Changes in:  Eating Sleeping Social Life Delusional Hallucinating Visual Audio Paranoid
Medical Problems:
Diabetic, current Accuchek: HTN: Seizure D/O, Last Seizure:
 Ambulatory Wheelchair/Walker Bed Rest Self Care Incontinent
Legal Problems:
Prior Treatment:
Administration on Call: Time:
Referred to Assessment Team: Time:
Psychiatrist Contacted: , MD Time: Admission Approved?:
If No, WHY?:
Transportation:  Yes No Company: INIT.:
Discharge plans/Aftercare placement:
Administrative Reviewer: Date:

Apollo Behavioral Health Hospital provides admission services 24 hours a day 7 days a week. Contact us at (225) 663-2881 or 1-855-435-4322.You can fax the referral packet to 225-355-1555

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