HOSPITAL FOLLOWUP
Client Information
Gender Identity
*
(not applicable)
Male
Female
Transgender Male
Transgender Female
Non-Binary (They/Them/Ze/Zir)
Unknown
Another Gender
Patient FirstName
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Patient LastName
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Preferred Name
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Date of Referral
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Medical Record Number
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Date of Birth
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Does the client have a phone number? If no, please enter zeros for the Primary Phone Number
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Yes
No
Primary Contact
Primary Phone Number
*
Is it okay to leave messages
Is it okay to leave messages
Yes
No
Comments (Extentions etc.)
Secondary Contact
Secondary Phone Number
*
Is it okay to leave messages
Is it okay to leave messages
Yes
No
Comments (Extentions etc.)
Preferred Times to Receive Contact (provide times between 8am - 8pm 7 days a week)
*
Alternate Contact Person
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Address
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City
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State
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Zipcode
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Clinical Information
Chief Complaint (include Psych, Chemical Dependency and Co-Occurring Disorder)
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History of self-harm or harm to others, including previous suicide attempts
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Is suicidal ideation a contributing factor to current presentation at ED?
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Yes
No
Unknown/Unable to access
Did the patient have a suicidal plan at the time of presenting to the ED?
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Yes
No
Unknown/Unable to access
Relevant psychosocial issues (e.g., housing, work, finances, relationship issues):
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Discharge Plan:
*
Facility Information
Name of Facility Making Referral
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Bay Area Hospital
Cedar Hills Hospital Inpatient Services
Cedar Hills Hospital Outpatient Services
Coquille Valley Hospital
Oregon Health & Science University
Other
Name of Facility Making Referral (Other)
Facility Staff Name
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Facility Contact Information (Phone Number)
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Electronic Signature: By choosing "Accept", I acknowledge that this patient has received information about Caring Contacts and agrees to participate in this program with Lines for Life.
*
Accept
Decline
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