Intake Form

When you call the PCL, a health navigator asks a few questions about you and the patient you are calling about. Most of the questions are reporting requirements as determined by the Washington State Health Care Authority.

The more information we have about the patient the better, but we will assist you using whatever information you have. Ideally, you will have the following information available:

Provider information (first-time callers only)

  • Provider first & last name
  • Direct phone (in case call is lost)
  • Email (for sending the written summary of the call)
  • Credential (ARNP, PA, MD, PhD, LICSW, SUDP, etc.)
  • Where do you work? (type of work site and name of work site)
  • City and county of practice
  • How did you hear about the PCL?

Patient information

  • Patient first and last name
  • DOB
  • Gender
  • Preferred pronouns
  • City of residence
  • On Medicaid?
  • Any insurance coverage?
  • Race, if known
  • Ethnic group and Ethnic background, if known

Case Outline Format

If you’d like more information about preparing to consult with the psychiatrist, learn more about the case outline format.