Behavioral Health Transfer Forms

If you are a facility who is transferring a patient to Kootenai Health’s Behavioral Health program or a family member of a patient being transferred, please use the relevant forms listed below.

For Youth Transfers:

Transfer Request Form (for facilities that are transferring a youth)

• Youth Transfer Request Form

Admission Packet (for families to complete)

• Patient Intake Form
• Acknowledgement of Custody and Consent for Discharge
• Medical History Questionnaire
• Release of Information
• Conditions of Admission to Kootenai Health
• Youth Communication List
• New Family Expectations Form

Information for families (about the unit your child is going to)

• Child (5-12 Years)
• Adolescent (13-17 Years)

For Adult Transfers

The following information will be needed in order to assess if we have the capacity to safely care for your patient.

• Demographic Sheet
• Current Medication List
• Allergies
• A current dictated History and Physical by a Medical Physician
• A current set of lab work including: Chemistry, Hematology, Urine, Toxicology, TSH, Pregnancy in fertile females and ETOH level if appropriate.
• Progress notes that state the reason the patient has presented to the ED

For more information about adult services, call 208.625.4870.