Charlie Health Professional Referral Form
Please use this form to provide information on clients you are referring to Charlie Health. Our goal is to make this process simple.
Professional Referral Source Contact Information
What is your name?
*
First Name
Last Name
Is this your first time referring to Charlie Health?
*
Yes
No
What state are you in?
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
What is your organization?
*
e.g. Children's Hospital of Austin
What is your role? (optional)
What is your email?
*
What is your phone number?
*
Format: (000) 000-0000.
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Patient Name
*
First Name
Last Name
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Is the person seeking help a teen or young adult?
*
Teen
Young Adult
Other
What city does the patient live in?
What state does the patient live in?
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Patient's DOB
*
-
Month
-
Day
Year
Date
Is there anything else you would like us to know about this patient that would help in ensuring a timely admissions process and effective care delivery?
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Next
Whose contact information are you providing?
*
Patient
Guardian
Patient's Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Email (optional)
example@example.com
Guardian's Name
*
First Name
Last Name
Guardian Relationship to Patient
*
Please Select
Father
Mother
Step Father
Step Mother
Grandfather
Grandmother
Uncle
Aunt
Brother
Sister
Guardian
Friend
Partner
Other
Guardian's Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian's Email (optional)
example@example.com
Who should Charlie Health reach out to?
*
Referent (me)
Client
Both Referent (me) and Client
What type of insurance does your patient have?
*
Commercial/Private
Medicaid
Other
I don't know
Would you like to provide additional patient insurance information?
*
Yes
No
Patient's Insurance Carrier
*
Patient's Member ID / Medicaid #
*
Patient's Group Number
Insurance Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Street
Street Address Line 2
City
State
Zip Code
Patient's Zip Code
Upload Insurance
Browse Files
Drag and drop files here
Choose a file
If available, please upload the patient's insurance card. If you don't have it, you can include the insurance member ID in the next field.
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Any other additional thoughts, questions or feedback for the Charlie Health team?
Referral notes
Patient Name 2.0
First Name
Last Name
Submit
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