Required Documents

for referring providers to complete

Fax the required forms and information to 1 (510) 374 – 4224

Required Documents

At the Time of Referral:

  • Copy of insurance card
  • Demographics form
  • Growth chart (BMI preferred, weight for age acceptable)
  • Psychiatric evaluation (including history of self-harm, violence, family support, and family situation)
  • Mental Health Progress Notes
  • Dietary Progress Notes
On the Day of Admission:
  • List of medications
  • 3-5 day supply of medications
  • COVID-19 Testing (Must be recent, within 5 days of admission)
    • Option 1: PCR or antigen test
    • Option 2: Rapid or home tests conducted
2-3 Days Before Admission and Again on the Day of Admission:
  • Medical Tests and Evaluations
Within 1 Week of Admission:
  • Weight and vitals
  • Updated mental health progress notes
Within 1 Month of Admission:
  • EKG
  • Labs (Magnesium, Phosphate, CBC+, TSH)
  • Comprehensive Metabolic Panel
Within 1 Year of Admission:
  • PPD or equivalent clearance for TB (licensing requirement, PPD can be read on site)
  • Labs (Magnesium, Phosphate, CBC+, TSH)
  • Comprehensive Metabolic Panel