Online Referral Request Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Referral
Emergent/Urgent
Emergent/Urgent
Routine
Referring Agency (include staff name, title, phone number, and email address for referral follow-up)
PATIENT INFORMATION Name, Date of Birth, and Age at time of referral:
Physical Address (include city, state, and zip AND county):
Evaluation Requested for the following service(s)
Child/Adolescent Mental Health
Child/Adolescent Substance Abuse
Adult Mental Health
Adult Substance Abuse
Comprehensive Clinical Assessment only
Outpatient Therapy
Medication Management
Insurance Information
Self-Pay/Uninsured
Private/Commercial Insurance (i.e. BCBS)
Medicaid
Medicare
Parent or Legally Responsible Person (if other than "self"):
Primary Phone Number
Secondary Phone Number
REASON FOR REFERRAL Please provide specific information of precipitating events that led to this referral.
The person for whom you are making this referral is aware of the referral.
Yes
No
The person for whom you are making this referral is willing to participate in an assessment and treatment recommendations.
Yes
No
Unsure, seeking additional information.
Are there any potential staff safety risks (select all that apply)?
Neighborhood safety risks
History of suicidal thoughts/attempt
History of homicidal thoughts/attempts
Aggressive animals/pets
Weapons in the household
Frequent psychotic episodes
Hostility toward a particular race or sex
None
Primary Care Physician Information Physician, Name and Address of Practice:
Physician Daytime Office Phone:
After-hours Phone Number:
Send
Should be Empty: