About this template
The Behavioral Health Referral Google Form template is designed to simplify the intake process for mental health clinics, private practices, and behavioral health facilities. By standardizing the information collected at the point of referral, providers can ensure they have the necessary clinical and contact details to assess patient needs efficiently and prioritize care appropriately.
This form captures essential patient demographics, primary reasons for referral, current medications, and specific program requirements. It is particularly useful for intake coordinators and clinical staff who need to gather comprehensive background information before a patient's first appointment. By using Doc2Form to deploy this template, your facility can reduce administrative bottlenecks and ensure a professional, consistent experience for every new patient.
Key features
- Standardized fields for patient demographics and contact info.
- Categorized sections for clinical history and presenting challenges.
- Dedicated fields for parent/guardian details for pediatric referrals.
- Clear, professional layout optimized for mobile and desktop.
- Easy to customize with your clinic's specific program offerings.
Use cases
New patient intake for outpatient mental health clinics.
School-based behavioral health service referrals.
Internal referral tracking between primary care and mental health dep…
Internal referral tracking between primary care and mental health departments.
Initial screening for specialized therapy programs.
What this form collects
- Patient Full Name (Short answer)Enter the legal name of the individual being referred.
- Date of Birth (Date)Format: MM/DD/YYYY.
- Contact Information (Short answer)Please provide the best phone number and email for the patient or guardian.
- Parent/Guardian Details (Paragraph)If the patient is a minor, please provide the name and contact info of the parent or legal guardian.
- Primary Language (Short answer)What is the patient's preferred language for communication?
- Reason for Referral (Paragraph)Briefly describe the primary reason for this referral and any specific goals for treatment.
- Presenting Challenges (Paragraph)What are the primary symptoms or challenges the patient is currently facing?
- Current Medications (Paragraph)List any current medications the patient is taking, including dosage if known.
- Type of Services Needed (Checkboxes)Select the type of care requested.
- Additional Documentation (Paragraph)Please paste a link to any relevant files (e.g., previous assessments, school reports) or describe the documents you wish to provide.
FAQ
What is the purpose of this referral form?
This form serves as a structured intake tool to collect necessary patient background, clinical history, and contact information before a formal assessment or appointment.
Can I add my own questions to this template?
Yes. Once you convert this template to a Google Form, you have full control to add, remove, or edit questions to match your clinic's specific intake requirements.
Is this form suitable for pediatric patients?
Yes, the template includes specific sections for parent or guardian contact information, making it appropriate for both adult and pediatric behavioral health services.
How do I share this form with referring providers?
You can share the form via a direct link, embed it on your clinic's website, or send it via email to referring physicians or school counselors.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.