Download Psychia​try Resident Referral Form

Harborview Medical Center
Outpatient Psychiatry Programs
Psychiatry Resident Continuity Clinic Referral Form
UW Residency Training Program
Thank you for referring your patient to Psychiatry Resident Clinic (PRCC). Please complete this form with the information
needed to determine eligibility for services in this program. COMPLETING THIS FORM DOES NOT
GUARANTEE PLACEMENT IN THE CLINIC. Refer to the back of this page for criteria.
PATIENT INFORMATION:
DATE:
Patient Name:
HMC#:
Daytime Phone #:
Address:
DOB:
Is Housing Stable?
Date of referral:
Form of Transportation:
REFERRAL FROM:
Referral From:
Phone/Pager Number:
Primary Care Provider:
Phone/Pager Number:
Email:
CLINICAL INFORMATION:
History of Present Illness:
Presenting Problem/Chief Complaint:
Diagnoses:
Services Requested:
Patient’s Desired Outcome:
Past Psychiatric History:
Previous Psychiatric Treatment:
(Please Include Meds)
Previous Suicide Attempts:
Previous Hospitalizations:
Substance Abuse History & Tx:
University of Washington Academic Medical Center
Pt. No.
Name:
D.O.B.
Harborview Medical Center – UW Medical Center
University of Washington Physicians
Seattle, Washington
Psychiatry Resident Continuity Clinic
Referral Form
Please return to HMC PRCC @ Mailstop 359896
206-744-3452 or FAX to 206-744-3427
Harborview Medical Center
Outpatient Psychiatry Programs
Psychiatry Resident Continuity Clinic
UW Psychiatry Residency Training Program
WHAT IS PRCC?
Psychiatry Resident Continuity Clinic is a general adult psychiatric outpatient program, located in
the 5-East Clinic. Administration is shared with the larger Psychiatry Clinic. Psychiatric services are
provided by residents in the University of Washington Psychiatry Residency Training Program
under the supervision of an attending psychiatrist.
SERVICES AVAILABLE


Medication management and evaluation.
Psychotherapy (including cognitive-behavioral and brief analytic)
PRCC IS NOT ABLE TO PROVIDE



Social Work Services
Case Management
Chemical Dependency Treatment
CRITERIA FOR TREATMENT IN PRCC
Ideal Patient Profile:
 Demonstrated history of compliance with outpatient care.
 Adequate social supports (including housing and transportation) such that case management is
not needed.
 Ability to wait for possibly up to several months for assignment to a resident.
 Clean and sober at least 6 months and is motivated to remain so.
 A level of acuity that is appropriate for non-urgent, non-emergency outpatient care.
REFERRAL PROCESS
1.
Financial Screen: Upon receipt of your referral, clinic administration will perform a financial
screening. Patients must have the means to pay for treatment, either through public assistance, private
insurance, or on a self-pay basis. Free care is not available. However, patients can apply for a lowincome allowance as determined by the hospital and U.W.P., which can result in reduced or waived
fees. Clinic staff will perform a financial screen to determine financial eligibility.
2.
Clinical Screen: The clinic will do its best to assess your patient based on the information you provide
on this form, However, completing this form does not guarantee placement in the clinic. Clinical
supervisors, the assistant residency training director and the chief resident need to ensure that residents
treat appropriate cases to meet their educational requirements. You will be informed in a timely
manner whether or not your patient is accepted into the program.
3.
Placement: There are factors that limit the number and types of patients that can be accepted into the
program. Because this is a teaching clinic, the number of residents and the amount of time they have
in clinic varies (i.e. at times the clinic may be full and there may be a waiting list for as long as several
months, especially for psychotherapy services). Referrals are closed if patients are not accepted within
3 months.
New patients needing immediate services for urgent or emergency matters should go
to either Crisis Intervention Services at Harborview Community Mental Health
Center, or to the Crisis Triage Unit (ER)
Please return to HMC PRCC @ Mailstop 359896
206-744-3452 or FAX to 206-744-3427