Behavioral Health Integration Form

A form patients use in a medical setting to authorize and coordinate discharge-planning assistance and access to behavioral health support services.

Use this template

Behavioral Health Integration

This service helps you coordinate the support you need after discharge.

By signing below, you agree to receive advanced discharge-planning assistance.

Name

Nombre

Apellido

Date

I have read the above information and agree to receive advanced discharge assistance

Coordinator

Date

Patient opted out of this free service

Post-Discharge Plan

Prescription and Appointment Details

Agrees to receive assistance in filling prescriptions?

Appointment type after discharge

Clinic Name

Appointment Date and Time

Contact

Phone Number

Thank you for trusting our care team.

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