PARTIAL HOSPITALIZATION PROGRAM
1801 North Front Street
Harrisburg, PA 17102
Phone: (717) 238-8852
FAX: (717) 238-0692
REFERRAL FOR SERVICES
Referral Source (name, agency, phone number, and email address):
_______________________________________________________________________
Is this a hospital referral? Yes or No (circle one)
Expected discharge date _________________________________
Date of referral received: ______________________ Seen within 5 days of referral received? Yes or No (circle one)
The consumer must be seen within 5 days of referral for Psych Eval if the referral is from a hospital.
Should the intake be scheduled through the referral source or directly through the consumer? ______________
___________________________________________________________________________________________________________________________
Consumer: _______________________________________________
DOB: _______________________
Sex: M / F Phone#: __________________________________
SS#: _________________________________
BSU#: _____________________________________
Type of insurance: __________________________________________________
If none, MA applied? Yes / No
*Please remind consumer to bring their insurance card to intake to copy.
Reason for Referral: ___________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Where is the consumer currently receiving services? ______________________________________________________________
(If currently open at Merakey Outpatient, PHP Intake Coordinator will request records.)
Does the consumer have a history or admit to current drug and/or alcohol use? If so, please describe:
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Does the consumer have a history or physical aggression/ideations? If so, please describe:
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
(Please note: an indication of D & A and/or aggression issues DOES NOT mean the consumer will not be
accepted into programming.)
Please include the following in this referral packet:
 Most current medication sheet*
 Most current psychiatric evaluation (within the last two years) *
 Proof of IQ if there is an IDD diagnosis*
 County Authorization (if necessary) *
 Agency intake
 Registration form
 Misc. records pertaining to consumer’s treatment history
*Please note that an intake will not be scheduled until this information is received.
Thank you for your cooperation in helping us obtain the necessary information for a consumer-friendly intake!
PLEASE DIRECT ALL REFERRALS ATTENTION TO: ALYSSA WILSON (ext. 211)