Behavioral Health Referral and Follow-Up Tracking Log

Tracks behavioral health referrals, appointment completion, follow-up outreach, and monitoring status while minimizing collected PII.

Referral Record

• Referral Date
  Date the behavioral health referral was placed.
• Referral Source
  Select the source of the referral.
• Reason for Referral
  Choose one or more referral reasons. Collect only what is needed for follow-up.
• Referral Priority
  Indicate the urgency of the referral.
• Patient Identifier
  Use the internal medical record number or other approved identifier. Do not enter SSN.
• Patient Name
  Optional if your workflow already links the record to a patient profile.

Appointment Status

• Was an appointment scheduled?
• Scheduled Appointment Date
  Show only when an appointment has been scheduled.
• Attendance Status
  Select the outcome of the scheduled appointment.
• Attendance Verified Date
  Date attendance was confirmed.
• Is additional follow-up needed?
  Use this to trigger progressive disclosure for outreach or monitoring.

Follow-Up Outreach

• Number of Outreach Attempts
  Count only documented outreach attempts related to this referral.
• Most Recent Outreach Date
  Date of the latest follow-up contact attempt.
• Most Recent Outreach Method
  Select the primary method used for the latest outreach.
• Contact Result
  Document the outcome of the latest outreach attempt.
• Barriers to Follow-Up
  Select any barriers affecting attendance or follow-up.
• Outreach Notes
  Briefly document the follow-up plan, using minimum necessary detail.

Monitoring and Closure

• Monitoring Status
  Current status of the referral tracking record.
• Monitoring Frequency
  How often the patient will be monitored while the referral remains open.
• Closure Date
  Date the referral tracking record was closed.
• Closure Reason
  Reason the referral tracking record is being closed.
• Escalation Needed?
  Check if the case requires escalation to a supervisor, care manager, or crisis pathway.
• Closure Summary
  Summarize the outcome and any remaining monitoring needs.

Consent and Audit Trail

• PII Notice Acknowledged
  Confirm that the submitter understands this form collects minimum necessary PII for care coordination.
• Consent to Contact for Follow-Up
  Use only if your workflow requires documenting patient consent for outreach.
• Submitted By
  Name or role of the staff member completing the log entry.
• Submission Date
  Automatically captured for audit trail purposes.
• Audit Trail Notes
  Optional internal notes for recordkeeping, edits, or follow-up actions.