Samaritan Behavioral Health

For Professionals – Referrals & Forms

Thank you for referring your clients to us. We are committed to providing them with the best care possible. We are also committed to helping you better serve your clients with mental health and substance abuse issues. Several tools are available to help do this. You may need to download the free Adobe Acrobat Reader.

Physician and Medical Office Referrals:

Thank you for referring your patients to us. We are committed to providing them with the best care possible. We are also committed to helping you better serve your patients in the mental health and substance abuse areas. Several tools are available to help do this:

  • The Physician Referral Form (35 KB Word doc) provides an online version of our standard referral form that you can download and print when referring patients to us.
  • The Summary of On-Going Treatment Form (49 KB Word doc)provides an online version of our standard referal form that you can download and print when referring patients for on-going treatment.

Children Service Division Referrals:

Thank you for your referral to Samaritan Behavioral Health, Inc. CSD Referral Packet (Word doc) provides an online version of our standard referral form that you can download and print when referring patients to us.

CSD Referrals are to be made by completing the attached packet of information and sending it to:

Samaritan Behavioral Health, Inc.
Access to Care
601 Edwin C. Moses Blvd
Dayton, OH 45417 or
Fax to 937-734-8252

A crisis or emergency referral should be sent to CrisisCare by completing the Intake packet designed for that program. CrisisCare can be reached at 224-4646.

Referrals to Samaritan Behavioral Health outpatient services must contain the following information in order for us to meet regulatory requirements and initiate our diagnostic assessment. After we have received the completed information, we will contact the foster parent to schedule an intake appointment. The CSD Intake Packet can be printed for completion.


SBHI Forms

Common SBHI forms are available for you to download and print:


Patient Education Materials:

Patient Education Materials covering a variety of mental health and substance abuse topics are available for you to download and print. You may need to download the free Adobe Acrobat Reader.

ADD/ADHD

Alcohol and Substance Abuse

Bullies and Bullying

Children

Eating Disorders & Obesity

Depression

Dual Diagnosis

General

Stress

Suicide

Trauma and Abuse


Related Web Sites:

Administration for Children & Families
This is the official website for the Administration for Children and Families (ACF) within the U.S. Department of Health and Human Services. ACF is responsible for federal programs that promote the economic and social well-being of families, children, individuals, and communities. The website includes a long listing of services for families, working with the ACF through initiatives, programs, contracts, grant opportunities, and much more.

Adults and Mental Health: A Report of the Surgeon General
This chapter from a larger report focuses on adult mental health. It discusses types of mental health disorders and their treatment, including anxiety disorders, mood disorders, and schizophrenia. It includes an extensive section on service delivery and other services and supports, such as consumer self-help, family advocacy and integrating service systems.

American Professional Society on the Abuse of Children

APSAC’s mission is to enhance the ability of professionals to respond to children and families affected by abuse and violence. This website includes information on their services, publications, resources and links. There is a nominal cost to order publications.

Anxiety Disorders
This section of the National Institute of Mental Health’s website focuses on Anxiety Disorders. It includes descriptions and discussion of the five major types of anxiety disorders, methods of treatment, news, research, and related information.

Bipolar Disorder
This website has a good range of articles about bipolar disorder, which go into greater depth than most. Information on current research is included, along with testing, the latest news and links to related topics.

Bipolar (Manic-Depressive) Disorder
Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out daily tasks.

Child Welfare Information Gateway
This organization is the resulting combination of the former National Clearinghouse on Child Abuse and Neglect Information and the National Adoption Information Clearinghouse. This site’s mission is to promote child safety and well-being by connecting child welfare, adoption and related professionals to timely, essential information. This site has a broad range of information on child abuse and neglect and preserving families, including federal and state definitions of abuse and neglect. This site also includes information on achieving and maintaining permanency and adoption. You can subscribe to free publications, too.

Domestic Violence & Mental Health Policy Initiative
This organization works to address the unmet mental health needs of domestic violence survivors and their children. The organization’s website includes a broad range of information about domestic violence, including publications, a newsletter, resources, links, and a section for survivors. This organization is also working to create a National Training and Technical Assistance Center on Domestic Violence, Trauma and Mental Health, funded by the U.S. Department of Health and Human Services, Administration on Children, Youth and Families.

Healthy Families America
This national program model is designed to help expectant and new parents get their children off to a healthy start. Families participate voluntarily in the program and receive home visits and referrals from trained staff. This program was developed by Prevent Child Abuse America and Ronald McDonald House Charities with the Freddie Mac Foundation. This website explains the program, identifies resources, research, and related publications.

Healthy Marriages Initiative (En Espanol)
This is part of the Administration for Children & Families website. It contains a broad range of information about this initiative, including activities; a marriage calculator; marriage initiatives for African Americans, Hispanics, and Native Americans; research, funding opportunities, and premarital and marital education programs.

Mental Health Medications
To review links to numerous articles about mental health medications, visit this site. Written by mental health professionals, these articles are concise and well-written. These pages are part of About.com, a New York Times subsidiary that provides information on a variety of topics.

National Center for Trauma-Informed Care
The Center for Mental Health Services’ (CMHS’s) National Center for Trauma-Informed Care (NCTIC) assists publicly-funded agencies, programs, and services provide a more supportive, comprehensively integrated, and empowering environment for trauma survivors. This web site provides resources, technical assistance, and training for professionals to raise awareness, help educate others, and foster a deeper understanding of the impact of trauma.

OhioMindsMatter.org
Minds Matter is a 3 year project sponsored by Ohio Department of Medicaid (ODM), Ohio Department of Mental Health and Addiction Services (OMHAS), and BEACON the (Best Evidence for Advancing Childhealth in Ohio Now!). This initiative is focused on children. Many children on Medicaid have complex behavioral health care needs, particularly children in foster care.

Play Therapy
This is the website of the Association for Play Therapy, an organization that fosters contact among mental health professionals interested in exploring and applying the therapeutic power of play to communicate with and treat clients – particularly children. The site includes information about the organization and play therapy, programs, education, training, credentialing, and resources.

The Prevention Researcher’s goal is to provide concise, timely and accessible snapshots of behavioral research to professionals working with adolescents and at-risk youth. While you have to pay for some of the information available, there are many free articles on timely but hard-to-find topics such as inhalants, gangs, body piercing, bullying and gay and lesbian youth.

Schizophrenia Resource Center*
This section is part of the Medscape website, which is devoted to a variety of clinical content, selected by the site’s editors. Content includes conference highlights, articles by experts, and much more.
*To access this extensive collection of information, you may need to register, which is free.

Systems of Care is a government-sponsored website devoted to providing information about the mental health of children and families. Systems of Care is a philosophy of how community-based services should work to meet the needs of children and families by recognizing the importance of family, school and community. The site includes numerous resources on publications, resources, research and training centers, programs, technical assistance, and Systems of Care alumni and partners.

Trauma and Abuse
This website, based in Europe, contains numerous articles on trauma and abuse broken down into nearly three dozen categories. These categories include Childhood Trauma, Abuse and Mutilation; Trauma, Traumatic Memories, Amnesia; Attachment, Neglect, Social Issues, Law, Ethics; Therapy Issues – Treatment Guidelines, Screening Tools and Questionnaires, and more.