Phq-9 Patient Health Questionnaire Page 2
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2BEHAVIORAL HEALTH SCREENING REFERRAL
To Be Completed by Provider or Healthcare Professional
Requesting Physician Information
Requesting Physician:
Medical Home: ___________________________________
Contact person:
Ext:
Date:
Client Information
-OR-
Clients Name: _______________________________________
Client Label
DOB: ________________ SS#: _________________________
Phone #:____________________________________________
Please identify the appropriate behavioral health referral type for the above client, based on the total calculated
scores for the answers reported on the behavioral health screening tools. This form is to be given to the on-site
behavioral health case manager, not the client.
Emergency Referral:
Any instance in which the provider has reason to believe that the client is at very high risk of life-
threatening, destructive, or disabling harm to self or others in the next 72 hours but is unsure about
•
initiating the Baker Act.
Psychosis, only if there is reason to believe that the safety of self/others is at risk in the imminent
OR
future.
•
An answer of "3 – Nearly every day" to question 9 on the PHQ-9 tool.
OR
•
Urgent Referral:
An answer of "2 – More than half the time" or “1 – Several days” to question 9 on the PHQ-9 tool.
•
A score of "severe depression" on the PHQ-9 (between 20 and 27)
OR
•
A score of "severe anxiety" on the GAD-7 (between 15 and 21) warrant an urgent referral.
OR
•
Routine Referral:
Anything else, including positive screenings for SSI-SA substance use and/or MDQ bipolar disorder.
Suspicions of psychosis: Any suspicion that a clinician may have that a patient may have a thought
•
disorder – auditory or visual hallucinations, delusions/fixed, unfounded, unrealistic and peculiar
•
beliefs, etc. (Unless there is reason to believe that the safety of self/others is at risk in the imminent
future – these would be emergency referrals).
Additional Comments:
Healthcare Professional Signature
Date
PROV-3B – Behavioral Health Scoring and Referral
- 2 -
(v5) 2/15/11
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