1. family and parenting

Screening & Referral Packet
Patient Eligibility Screening:
1. Is the patient uninsured? ◻ ️ YES ◻ ️ NO - Ineligible
2. Household income within 150% of Federal Poverty Guidelines? ◻ ️ YES ◻ ️ NO - Ineligible
How many people are in the patient’s household? _________
Approximate TOTAL gross monthly household income: $ _________
If household income exceeds that indicated below, the patient is not eligible for services:
3. Seeking mental health treatment services and not currently in crisis? ◻ ️ YES ◻ ️ NO - Ineligible
Presenting Problem(s): _______________________________________________________________
**The Polizzi Clinic ONLY provides psychiatric services and does NOT provide crisis intervention,
substance abuse treatment, counseling, disability evaluations, or pain management.**
Number in
Household
Gross Annual
Income
Gross Monthly
Income
Approximate Full-Time
Hourly Income
1
$17,655
$1,471
$8.49
2
$23,895
$1,991
$11.49
3
$30,135
$2,511
$14.49
4
$36,375
$3,031
$17.49
5
$42,615
$3,551
$20.49
6
$48,855
$4,071
$23.49
7
$55,095
$4,591
$26.49
8
$61,335
$5,111
$29.49
4. Is the patient taking / seeking any controlled medications? ◻ ️ NO
◻ ️ YES - See below
**The Polizzi Clinic does not prescribe controlled medications, with the exception of stimulant
medication for children and adolescents under age 18 with a primary diagnosis of ADD/ADHD.**
List all current medications and doses:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Rev. 03/2015
Page 1 of 3
Polizzi Clinic - 515 E 4500 S G220, Salt Lake City, Utah 84107 - 801-277-7740 - Fax 801-277-7750
Screening & Referral Packet
Patient Referral
Date _____________
Fill out after all eligibility criteria have been met on the screening.
Full Name: _________________________________________________ Birth Date: ____ / ____ / ____
Parent/Guardian Name (if under 18): ______________________________________________________
Address: _______________________________________ City: ____________________ ZIP: ________
Home Phone: _________________________________ Cell Phone: _____________________________
Email (optional): ______________________________________________________________________
____________________________________________________________________________________
Clinician Evaluation (Please circle one indicative of overall well-being)
1
2
3
4
5
6
7
Normal
Not at all ill
Possible or
borderline ill
Mildly ill
Moderately ill
Markedly ill
Severely ill
Extremely ill
Referral Site Contact Information:
Referral Source: ___________________________________ Phone: ____________________________
Address: _________________________________________ Fax: _______________________________
Referring Clinician & Credentials: _________________________________________________________
Email (optional): ______________________________________________________________________
• Submit the completed form: Fax (801) 277-7750 or email to [email protected]. Please note
that we will NOT schedule the patient unless we have received this faxed form.
• Advise the patient to call the Polizzi Clinic at (801) 277-7740 to schedule their first visit. The patient
MUST initiate contact to schedule an appointment.
• Operating Hours: Mondays & Tuesdays 9 AM – 4 PM with limited Saturday services as needed.
Please leave a message if contacting outside of operating hours.
Rev. 03/2015
Page 2 of 3
Polizzi Clinic - 515 E 4500 S G220, Salt Lake City, Utah 84107 - 801-277-7740 - Fax 801-277-7750
Screening & Referral Packet
FOR THE PATIENT:
You or your child has been referred to the Polizzi Clinic for no-cost psychiatric services. The Polizzi Clinic
does NOT provide psychological testing, counseling, disability evaluations, pain management, or
substance abuse treatment. The Polizzi Clinic serves children, adolescents and adults who are uninsured
and low-income.
Step 1: Please call (801) 277-7740 to schedule your first visit.
We are open on Mondays and Tuesdays from 9 AM to 4 PM. Your first visit must be on a MONDAY
between 9 AM and 12 PM or 1 PM and 3:30 PM. Please leave a message if calling outside those times
and we will call you back.
Step 2: Come in for your first visit.
**We are located on the NORTH EAST CORNER OF 500 EAST AND 4500 SOUTH. Our entrance is
on the south side of the building on the top floor. Bus lines 45 and 205 stop out front.**
Your first visit will be a screening appointment with our patient advocate where we will confirm eligibility,
request prior medical records, connect you with additional resources, and schedule an initial evaluation.
Please be sure to bring:
• Photo ID
• Proof of Household Income
• Month of paycheck stubs for all wage earners OR
• Most recent W-2 forms OR
• 3 months of bank statements OR
• Proof of food stamps or other state assistance OR
• Letter from employer, including contact info, hourly
rate, and hours per week
• Any relevant medical records or contact information
for your current or past physician and/or therapist(s).
What to Expect:
The Polizzi Clinic provides psychiatric services for those
who lack insurance coverage and the ability to pay for
services elsewhere.
Patients typically receive 5 to 7 visits across a period of
time unique to each patient with the goal of reducing mental health symptoms and transitioning you or
your child to a primary care provider to maintain care.
¿No hable inglés?
Please let us know so that we can arrange an interpreter for your services.
Por favor, háganos saber que podemos arreglar un intérprete para sus servicios.
We look forward to serving you!
Rev. 03/2015
Page 3 of 3
Polizzi Clinic - 515 E 4500 S G220, Salt Lake City, Utah 84107 - 801-277-7740 - Fax 801-277-7750