Client Referral Form | Bridge House/Grace House

Name

First Last

Gender

Male

Female

If Female, are you pregnant?

Yes

If yes, when are you due?

SSN

DOB

Age

Race/Ethnicity

Marital Status

Never Married

Married

Separated

Divorced

Widowed

Current Address

Street Address Address Line 2 City State ZIP Code

Parish

Contact Name

First Last

Contact Phone

Contact Email

Do you have Medicaid?

Yes

Provider Name:

Do you have Medicare or Private insurance?

Yes

If under 26, are you on your parent’s insurance?

Yes

Are you employed?

Yes

Other sources of income:

Disability

Retirement

Food Stamps

Are you a Veteran?

Yes

Do you qualify for Veteran Benefits?

Yes

Current Substance Abuse

Date of Last Use

Substance

How much?

Have you used drugs intravenously?

Yes

If yes, date of IV use and substance:

What is/are your drug(s) of choice? Check all that apply

Alcohol

Marijuana

Heroin

Cocaine

Benzodiazepine

“Pain Pills”

Methamphetamines

Other

Legal status for seeking treatment:

Voluntary

Court Ordered

Are you a convicted sex offender?

Yes

Are you currently on probation / parole?

Yes

If yes, please list the Name of Probation/Parole Officer, Contact Number, Parish, and Reason:

Are you involved with the Department of Children and Family Services?

Yes

If yes, please list the Name of Case Worker, Contact Number, Parish, and Reason:

Have you been arrested in the last 30 days?

Yes

If yes, how many times?

Have you ever committed acts of arson?

Yes

Have you ever tried to harm an animal?

Yes

Do you have any psychiatric diagnosis or other mental health issues?

Yes

If yes, please explain:

Do you currently have a provider for any psychiatric diagnosis or other mental health issues?

Yes

If yes, please list the provider:

Are you currently having any thoughts about ending your life or wanting to die?

Yes

If yes, please explain:

Are you currently having any thoughts about wanting to hurt or harm someone else?

Yes

If yes, please explain:

Do you have any known medical issues or concerns (diabetes, history of seizures, chronic pain, etc)?

Yes

If yes, please explain:

Do you have a provider for any of your medical issues or concerns?

Yes

If yes, please list the provider:

If yes, please explain:

Are you currently taking any medications?

Yes

If yes, please list Medication Name, Dosage, Frequency, When did you start taking it? Is it effective? Does it work?

Do you currently have a 30 day supply of your medications?

Yes

Who is the current provider of your medications?

Are you currently using a MAT?

Yes

If yes, check current MAT below:

Methadone

Naltrexone

Sublocade Injection

Suboxone

Subutex (only allowed if pregnant)

Vivitrol

If using Sublocade or Vivitrol, Date of next Shot:

Who is the prescriber/agency for MAT?

Supplemental Information

Hospitals, detox facilities and other treatment programs: Please include the following medical records with the referral: 1) History and Physical 2)TB Test 3)Medication List 4) Nursing Assessment 5) Biophysical History 6) Psychiatric Evaluation 7) Other Pertinent Information
ALL UPLOADS MUST BE IN PDF FORMAT

Judicial system / court referrals: Please include a release of information through the court system for our staff to communicate with the court system and any court order mandating treatment.

Please upload supplemental information. Or submit in one of the following ways:
1. Fax to 504-821-7296
2. Email to clinical@bridgehouse.org (Include in subject line: [Client Name], Online Client Referral Form Submitted [Date of Submission], Additional Medical Documents or Additional Court Documents)
3. Turn in at our lobby at 4150 Earhart Blvd during business hours (M-F 8am-4:30pm)

History and Physical