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)
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)
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
- 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.