Graceland Psychiatry and TMS Center

Dual Diagnosis IOP / PHP Referral Form

2411 Northeast Interstate Loop 410, Suite 112 · San Antonio, TX 78217-6644

Use this form to refer a client to Graceland's Intensive Outpatient (IOP) or Partial Hospitalization (PHP) program.

Fields marked * are required. Referrals can be faxed, emailed, or submitted directly by a case manager, discharging facility, or referring provider.

Referral Source

Referring facility or provider *

Contact information *

Date of referral

Patient Demographics

Patient full name *

Date of birth *

Phone number *

Email address

Current addressStreet, city, state, ZIP

Emergency contact

Insurance Information

Insurance carrier *

Plan name, if "other"

Member ID number *

Group IDIf listed on the card

Member services phone number

Level of Care Requested

Program *

IOP — Intensive OutpatientPHP — Partial HospitalizationUndetermined — let clinical team assess

Discharge date from current level of care *Date the patient is leaving (or left) their prior treatment setting

Requested IOP/PHP start date *

Substance Use

Drug of choice (DOC) *

Other substances usedList any additional substances used regularly or of clinical concern

Authorization & Signature

Release of information

By signing below, the referring provider/facility confirms this information is accurate to the best of their knowledge and authorizes Graceland Psychiatry and TMS Center to contact them regarding this referral, including for records exchange needed to coordinate care.

Signature *

Questions about this referral? Call Graceland Psychiatry and TMS Center at 210-868-5801.

Graceland Psychiatry and TMS Center · IOP/PHP Referral Form