Capital Health Group Client Referral Form

Client Referral
CHG uses HIPAA-compliant video platforms that protect the privacy of clients and the confidentiality of protected personal health information.

Steps to successful referral and service placement:
- Complete referral form online (below)
- Receive call back within 2 business days
- Schedule virtual or in person assessment for services
- Receive confirmation of CHG staff assigned to provide care
Client Information
Name(s)
Date of Birth

MonthDayYear
Age
Gender Identity

ManWomanThird gender/Non-binaryOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Service Requested (check all that apply)

Intensive In-HomeOutpatient TherapyPlay Therapy & Expressive ArtsOther
Insurance Type
Insurance Member ID
Insurance Group #
Please upload a photo of the FRONT of your insurance card

Cancelof
Please upload a photo of the BACK of your insurance card

Cancelof
Please upload a photo of the FRONT of your ID Card

Cancelof
Please upload a photo of the BACK of your ID Card

Cancelof
Give a description of the reason services are requested for the individual
List referrals to other services for further assessment
Please indicate whether the client is on a waiting list for service with another provider or entity. If applicable list the admission to another service.
Signature*

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Client Referral