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Editha House Online Referral Form
Editha House Online Referral Form
Editha House Online Referral Form
ehadmin
2019-01-27T04:48:36+00:00
Name
REFERRAL INFORMATION
Referral Agent
*
Title
*
Email Address
*
Phone
Medical Facility
*
PATIENT INFORMATION
Patient First Name
*
Patient Last Name
*
DOB
*
Street
*
City
*
State
*
Zip Code
*
Gender
*
Male
Female
Home Phone
*
Cell Phone
*
Miles from Residence to Treatment Facility
*
Email Address
*
Diagnosis
*
Treatment
*
Name of Employer
*
Are there any medical problems which may affect the patient’s condition while staying at Editha House?
Speaks and/or understands English?
Yes
No
Has an infectious disease or infectious disease symptoms?
Yes
No
Been convicted of a violent crime, domestic violence, crime against a child, theft, and/or illegal drugs?
Yes
No
On probation or parole?
Yes
No
Has a civil protection order against them?
Yes
No
Been required to register on the state or National Sex Offender Registry?
Yes
No
Are you a smoker?
Yes
No
Does the Patient carry a weapon?
Yes
No
TREATMENT INFORMATION
Treatment Start Date
*
Treatment End Date
*
Estimated Time of Arrival
*
Treatment Facility
*
Street
*
City
*
State
*
Zip Code
*
DOCTOR INFORMATION
Patient’s Doctor
*
Phone
CAREGIVER INFORMATION
Caregiver Name
*
DOB
*
Street
*
City
*
State
*
Zip Code
*
Gender
Male
Female
Home Phone
*
Cell Phone
*
Relationship to Guest
*
Speaks and/or understands English?
Yes
No
Has an infectious disease or infectious disease symptoms?
Yes
No
Been convicted of a violent crime, domestic violence, crime against a child, theft, and/or illegal drugs?
Yes
No
On probation or parole?
Yes
No
Has a civil protection order against them?
Yes
No
Been required to register on the state or National Sex Offender Registry?
Yes
No
Are you a smoker?
Yes
No
Does the Caregiver carry a weapon?
Yes
No
COMMENTS
Additional Comments
*
VERIFICATION
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