Forms

• Hub Fax Cover Sheet
• Mental Health Background Form
• Mental Health Background Form-Cover Letter
• Patient Consent and Authorization
• Patient Release of Information
• PCP Needs Assessment
• Provider Data Sheet
• Referral Packet
• Referral-Staffing Form
• Satisfaction Survey – Patient/Parent
• Satisfaction Survey – Physician
• Satisfaction Survey – Young Adult

Screening Tools

Please refer to the Primary Care Screening Algorithm for guidance on when to administer various screening tools. An alphabetical list of a variety of rating scales/ screening tools is located below.

• Columbia Suicide Severity Rating Scale
• GAD 7
• Pediatric Symptom Checklist-17 (PSC-17) – English
• Pediatric Symptom Checklist-17 (PSC-17) – Spanish
• Pediatric Symptom Checklist-17 (PSC-17) – Youth
• PHQ-9
• SNAP IV-18
• SWYC-12 Month
• SWYC-24 Month
• SWYC-36 Month