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Run: Behavioral Health Referral and Follow-Up Tracking Log

Track behavioral health referrals, appointment completion, follow-up outreach, and closure in one log with minimal PII and a clear audit trail.

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Referral Record

Referral Date (required)

Date the behavioral health referral was placed.

Referral Source (required)

Select the source of the referral.

Reason for Referral (required)

Choose one or more referral reasons. Collect only what is needed for follow-up.

Referral Priority (required)

Indicate the urgency of the referral.

Patient Identifier (required)

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? (required)

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? (required)

Use this to trigger progressive disclosure for outreach or monitoring.

Follow-Up Outreach

Number of Outreach Attempts (required)

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 (required)

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.

Yes No N/A

Closure Summary

Summarize the outcome and any remaining monitoring needs.

Consent and Audit Trail

PII Notice Acknowledged (required)

Confirm that the submitter understands this form collects minimum necessary PII for care coordination.

Yes No N/A

Consent to Contact for Follow-Up

Use only if your workflow requires documenting patient consent for outreach.

Submitted By (required)

Name or role of the staff member completing the log entry.

Submission Date (required)

Automatically captured for audit trail purposes.

Audit Trail Notes

Optional internal notes for recordkeeping, edits, or follow-up actions.

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