Rocky Mountain Crisis Partners - V2 External Hospital Follow-up Enrollment

Section

Welcome to Follow-up Services with Rocky Mountain Crisis Partners

We offer supportive phone contact at least once a week for at least a month. Our goal is to provide ongoing support to you and assist with providing referrals and resources as needed. We want to make sure that you are set up for success after you leave the hospital so that you do not need to return to the hospital for a mental health concern.

The contact form below will enroll you into the RMCP Follow-up program free of charge.

Note: RMCP is a HIPAA Compliant organization. This form and transmission of the submitted information has been secured in accordance with HIPAA compliance and security standards.

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Hospital Location*

Other Hospital Name

Hospital Staff Name*

First Name

Last Name

Hospital Staff Call Back Number*

What is the best time of day to call?

What is your preferred time to call?

Participant Name*

First Name

Last Name

Non-English Speaker

How do you identify your gender?*

Participant Phone Number*

Participant Date of Birth*

Participant Zip Code*

Is the participant under the age of 18?*

Yes

Is the participant within the ages of 12 -18?

Yes

Parent/Guardian Name

First Name

Last Name

Best number to reach parent/guardian:

Do you give your parent/guardian permission to discuss and have access to the information you share in this program?

Yes

As parents/guardians of a child with mental health concerns we know that you also could benefit from support and follow-up, so even if your child does not wish to engage with us we are still able to provide services to you.

Please indicate below who would like to receive follow-up services:

Child

Parent

Both

Can we leave a voicemail?*

Yes

If someone other than you answers the phone can we disclose who we are?*

Yes

Are any of these a part of your reason for having contact with the hospital today?

None

Substance Use

Suicidal Ideation

Veteran Status

Which type of Follow-Up Specialist is preferred for the follow-up phone calls?*

Brief description of what brought you into the hospital and any relevant hand-off information from discharge?*

Hospital Date of Visit*

Please note that it is an expectation of the program that the patient be contacted within 24 hours of discharge.

Approximate Date/Time of Discharge

Hidden

What is the best time of day to call?

Approximate Time of Discharge

Hospital Date of Discharge

What is the best time of day to call?

What is your preferred time to call?