Outpatient Therapy Referral Form
Client Name
*
Date
*
/
Month
/
Day
Year
Date
Sex
*
M
F
DOB
*
SSN
*
Client's Preferred Language:
*
Primsary Insurance Type
*
Insurance ID
*
Policy Holder
*
Policy Holder DOB
*
Address
*
Home #
*
Cell #
*
Work #
*
Email:
*
example@example.com
Referred by (if applicable)
Phone
Reason for Referral/Goals: (symptoms, ,behavioral/social/emotional functioning of youth/family, focus of treatment)
*
Family's Preference for Scheduling:
*
SU
M
T
W
TH
F
SA
Times
*
General Mental Health Coverage:
Copay
*
Deductible
*
Authorization Required?
*
Yes
No
Additionallnformation
*
Verified by
Date
/
Month
/
Day
Year
Date
Insurance Representative
Phone #
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Should be Empty: