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Outpatient Forms

Outpatient Referral Packet
Outpatient Daily Check In
Crisis Safety Plan
Release of Information

Outpatient Referral Packet

Program Referral

Individual Therapy

Family Therapy

Group Therapy

Intensive Outpatient Program (please include physician order)

Patient Information

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Age(Required)

Date(Required)

MM slash DD slash YYYY

SSN(Required)

Gender Identity(Required)

Nonbinary

Other

Pronouns

He/Him

She/Her

They/Them

Mental Health Diagnosis

Legal Guardian Information

Full Legal Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Parent Information (if different than above)

Full Legal Name

First Middle Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

I Have Insurance

Yes

Insurance Information (please include a copy of the insurance card)

Name of primary insurance(Required)

Group #(Required)

Policy #(Required)

Policy Holder(Required)

DOB of Policy Holder(Required)

MM slash DD slash YYYY

Contact # to Insurance(Required)

Emergency Contact (will be contacted in the event of physical/mental health emergency)

Full Legal Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Relation to Patient(Required)

Patient Questionnaire

What symptoms or problems are you hoping to address?(Required)

Do you have a current recommendation for outpatient treatment?(Required)

Yes

If yes, who referred you?(Required)

If yes, what specific service have you been referred to?(Required)

Where have you been treated for this/these symptoms or problems (or other symptoms/problems) before?

Outpatient provider/program

When

Outpatient provider/program

When

Have you ever been hospitalized for a psychiatric condition?

Yes

Inpatient Program

Inpatient provider/program(Required)

When(Required)

Inpatient provider/program(Required)

When(Required)

Are you currently taking psychiatric medications?

Yes

Medications

If yes, prescriber:(Required)

List any medications and any side effects:(Required)

What did you find most helpful in your previous treatment?

What did you find least helpful in your previous treatment?

Telehealth Assessment

WBI clinic outpatient services are provided through telehealth video services which are secure and follow federal safety standards. While teletherapy is unique and designed to meet the needs of the patient and family and can be provided in the comfort of your own home, it is both the patient and the provider’s responsibility to ensure confidentiality. Providers will work with the patient and their family to support the comfort of teleservices, privacy for all patients, and ensure teleservices are provided appropriately. Patients who are unable/uncomfortable with receiving teleservices will be provided referrals to other programs, when available.

Telehealth Assessment Participants

Patient Name(Required)

First Middle Last

Date of Assessment(Required)

MM slash DD slash YYYY

Guardian Name(Required)

First Middle Last

Access Questions

Does the patient have access to internet/cellular service that can sustain video and audio streaming for up to 3 hours daily?(Required)

Yes

Does the patient have access to a device that can sustain video and audio streaming for up to 3 hours daily?(Required)

Yes

Does the patient have a secure/private space where they can participate in virtual services?(Required)

Yes

Parent/Guardian/Adult at Residence attest to providing/ensuring privacy to the patient while they are participating in services?(Required)

Yes

Do you have any concerns that may keep you from participating in telehealth services?(Required)

Yes

If yes, explain:(Required)

CAPTCHA

Outpatient Daily Check In

Date(Required)

MM slash DD slash YYYY

Patient Name(Required)

First Last

Safety screening

Address of my physical location if different than on my safety protocol sheet:(Required)

Emergency contact person, if different that on safety protocol sheet:(Required)

Emergency support services, if different than on safety protocol sheet:(Required)

Columbia Suicide Severity Rating Screen

1. Since last asked, have you wished you were dead or wished you could go to sleep and not wake up?(Required)

Yes (if yes, Low risk)

2. Since last asked, have you actually had any thoughts of killing yourself?(Required)

Yes (if yes, Low risk)

Risk Formulation

Persons suicide risk is:(Required)

Low

Moderate

High

Describe(Required)

Informed MD/NP/Primary Therapist & updated if “yes” to 2 or more on Columbia-Suicide Severity Rating Screen.(Required)

Informed MD/NP/Primary Therapist & updated if “yes” to 2 or more on Columbia-Suicide Severity Rating Screen.

Interventions

Interventions(Required)

Updated Crisis Safety Plan

Spoke with designated emergency contact

Sent to nearest ED

Referred to inpatient

Assessment of access to lethal means

Other

Other:(Required)

CAPTCHA

Crisis Safety Plan

Recognize your warning signs and use your coping skills to keep yourself safe and healthy.

Patient Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY

Email(Required)

Triggers and Stressors(Required)

(Behaviors, situations and circumstances that put you at emotional risk)

Warning Signs(Required)

(Your behavior signals that show you’re growing more and more at risk)

My Coping Skills(Required)

What I can do to be calm and stay safe IN THE MOMENT

Things to do(Required)

My goals for healthy behavior

People to contact(Required)

911

WBI Therapist: 307-237-7444 For emergencies related to this stay.

WBI Physician

National Suicide Prevention Lifeline www.suicidepreventionlifeline.org 1-800-273-TALK(8255)

Patient/Resident does not have access to:(Required)

Prescription medications for use other than as prescribed

Weapons

Lethal medications

Other means of self-harm

This has been verified by:(Required)

(Parent/Guardian or Support Person)

Reminders(Required)

Take medications as ordered – do not change the dose or time unless directed by your physician.

If you experience side effects from your medications – notify your outpatient provider or PCP

For Children/Adolescents – Medication should be kept out of reach and in a secure place

Keep all aftercare appointments as scheduled – take your copy of aftercare plan to your appointment

CAPTCHA

Healing Begins Here

We are here to help you take the next step in continuing your recovery.

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