23-Hour Crisis Stabilization Referral Form Referring Person Name: Name Agency / Organization Title / Role: Phone Number Email Date of Referral: Individual Being Referred Full Name Date of Birth Email Gender Phone Number Address Emergency Contact Name: Emergency Contact Phone Number Reason for Referral: Current Behavorial Health Concerns: Is the individual currently experiencing a crisis? Yes No Please describe current symptoms or behaviors: Anxiety Depression Emotional distress Suicidal thoughts Homicidal thoughts Psychosis Mood instability Behavioral concerns Other Is there an immediate safety concern? Yes No If yes, explain: Is the individual medically stable? Yes No Unknown Any known medical concerns: Current mental health provider: Current medications: Primary care physician: Support system involved: Insurance Provider: Member ID: Medicaid / Medicare Number: Referral Outcome Needed Crisis assessment Observation and stabilization Safety planning Nursing support / medical monitoring Care coordination Referral for ongoing services Other: Additional Information Send
