Request for Medication Refill Form
South Central Crisis Service
On-Call Clinician:
*
First Name
Last Name
Date of Call:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time Call Began:
*
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Hour
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Minutes
AM
PM
AM/PM Option
Caller's Name:
*
First Name
Last Name
Relationship to Client:
*
Caller's Phone Number:
*
-
Area Code
Phone Number - If unknown, enter "(000) 000-0000."
Client Name:
*
First Name
Last Name
Client's Phone Number:
*
-
Area Code
Phone Number - If unknown, enter "(000) 000-0000."
Age of Client:
*
If unknown, enter "00."
Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
If unknown, enter "01-01-1000."
Gender of Client:
*
Male
Female
Other
Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Prescriber:
*
First Name
Last Name
Agency:
*
Pharmacy Name:
*
Pharmacy Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy Phone Number:
*
-
Area Code
Phone Number - If unknown, enter "(000) 000-0000."
Reason for Refill Request:
*
Ran Out
Other
Medications Requested (Please list amounts and dosage):
*
1) Are there any difficulties other than a medication request that you would like to discuss today?
*
Yes
No
N/A
2) Are you taking your medication as it has been prescribed to you?
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Yes
No
N/A
3) Have you used any drugs or alcohol today?
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Yes
No
N/A
If yes, please explain:
4) Is this caller logical and goal directed?
*
Yes
No
N/A
5) Did any concerns arise from these questions? (If so, completion of the consumer telephone triage form is required)
*
Yes
No
N/A
Disposition:
*
Alert sheet referenced?
*
Yes
No
N/A
Was there a problem with the case?
*
Yes
No
If yes, please provide details:
Clinician Signature:
*
Time Call Ended:
*
1
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11
12
:
Hour
00
01
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58
59
Minutes
AM
PM
AM/PM Option
Total Time of Call:
Total Minutes
Type of Call
*
Routine
Urgent
Agency receiving form:
*
BHcare Shoreline
BHcare Valley
Bridges Healthcare, Inc.
Clifford Beers
Connecticut Mental Health Center
Fellowship Place
West Haven Mental Health Center
Yale Behavioral Services at Hamden
Out of Catchment Area-jhagelston
Submit
Should be Empty: