Circle of Hope PHP - Davison, MI - Referral Form

Never Lose Hope

Give Us a Call Today

(810) 214-1750

Hours

Monday - Friday:

8:00AM - 2:30PM

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Home
About Us
Services
Contact Us
Careers
For Providers
- Referral Form
For Patients
- Inquiry Form

Inquiry Form

Inquiry Form - Patients

This is a pre-screening form used as a referral tool to assess if you meet clinical and medical appropriateness to be referred on to complete our full-length intake assessment. Acceptance of the client to PHP or IOP is based on the full-length intake assessment.

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Date:

Name:

Date of Birth:

Address:

Phone Number:

Legal Guardian Name (if applicable):

Guardian Contact Phone Number (if applicable):

Blank Space

Mental Health and Treatment:

Mental Health and Treatment:

Do you currently have a Mental Health Diagnosis?

Yes

No

If yes, please list:

Seeking:

PHP

IOP

What is the reason for you seeking treatment?

Has there been an increase in psychiatric symptoms despite your participation in outpatient treatment? If so, check appropriate box(es):

Depression

Anxiety

Psychosis

OCD

Risky Behavior

Suicidal Ideation

Homicidal Ideation

Other

If Other:

Please provide a brief description for any checked boxes:

Blank Space

Brief Suicide and Safety Assessment:

Brief Suicide and Safety Assessment:

On a scale of 1 to 10 (10 being strongest), how anxious are you?

On a scale of 1 to 10 (10 being strongest), how depressed are you?

Have you ever had thoughts or feelings that you didn’t want to live?

Yes

No

Do you currently feel that you don’t want to live?

Yes

No

How often do you have these thoughts?

When was the last time you had thoughts of dying?

On a scale of 1 to 10 (10 being strongest) how strong is your desire to kill yourself?

Do you feel hopeless and/or worthless?

Yes

No

Have you ever tried to kill or harm yourself before?

Yes

No

Is there anything that would stop you from killing yourself?

Yes

No

Thank you for contacting us.

We will get back to you as soon as possible.

If you do not hear back from us within 24 business hours, please call 810-214-1750.

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Contact Us Today

Contact Us

Name:

Email:

Phone:

Message:

Thank you for contacting us.

We will get back to you as soon as possible.

If you do not hear back within 24 business hours, please call us at 810-214-1750.

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Please try again later.

CIRCLE OF HOPE PHP

ADDRESS: 9171 Lapeer Road, Suite 500, Davison, MI 48423

Hours: Monday - Friday, 8:00AM - 2:30PM

Phone: 810-214-1750

Fax: 810-214-1753

CALL TODAY

(810) 214-1750

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