Palms Referral Form - Palms Behavioral Health

613 Victoria Lane Harlingen, TX 78550 | Phone: (956) 365-2600 | Fax: (956) 421-1033
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Things NOT to bring with you:
 Sharp items, toiletries, valuables or jewelry
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Things to bring with you:
 3 sets of clothes
 Insurance card and identification card
 Your medications
 Shoes without shoelaces
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INPATIENT ADMISSION
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Initial Consultation Referral
Referral Source:_________________________________ Admit Order to:_________________________________
Primary Care Physician:_________________________________________________________________________
Contact Person:________________________________ Office Phone:___________________________________
PATIENT INFORMATION
Patient Name:________________________________ Date of Birth:_________________________________
Patient Home Phone #:_________________________ Alternate #:__________________________________
Insurance:________________________________________________________________________________
Diagnosis:________________________________________________________________________________
________________________________________________________________________________________
Special Instructions:________________________________________________________________________
________________________________________________________________________________________
_____/_____/_____ (DATE) Patient seen by physician and referred to Palms Behavioral Health Hospital for admission.
__________________________________________
REFERRING PHYSICIAN’S NAME
__________________________________________
DATE
__________________________________________
PRINT NAME
__________________________________________
TIME
Initial Consultation Referral Form 8/4/2016