Heart and Solutions Referral Form
In order to complete this form in its entirety, you will need the following information for the person seeking services: Social security number, insurance details and insurance subscriber information.
Upon completion of this form someone from Heart and Solutions will be in touch within 5 business days.
If you experience a technical difficulty with this form, please contact us at help@heartandsolutions.net
Provider(s) Requested:
Open to Telehealth?
Yes
No
Open to In-Person?
Yes
No
Location Requested (check all that apply)
Cedar Rapids
Grundy Center
Waterloo
Davenport
MasonCity
Ames
Other
Service Requested (check all that apply):
Behavioral Health Intervention Services (BHIS) - Behavioral health intervention services for children ages 4-19 that can be held in home, in office, or in school
Individual Therapy
Family Therapy
Couples Therapy
Is anyone in your household a registered sex offender or have any active or pending charges against a minor? *Please note that your answer may not preclude you from receiving mental or behavioral health services, but may limit the location in which you receive services.
*
Yes
No
Presenting Problem:
*
Do you personally know anyone who works at Heart and Solutions?
Please Select
Yes
No
Please type who the person is
Does anyone in your immediate family have therapy with anyone at Heart and Solutions?
Yes
No
Please list provider(s)
Are there any providers that you specifically do not want to work with?
Yes
No
Please list provider(s)
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CLIENT DEMOGRAPHICS
Full Legal Name:
Preferred Name:
Email Address:
example@example.com
Home Address: Physical address is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address: If different than Home Address.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Date:
-
Month
-
Day
Year
Date
Main Phone:
*
Please enter a valid phone number.
May we leave a detailed message?
Yes
No
Secondary Phone
Please enter a valid phone number.
May we leave a detailed message?
Yes
No
Date of Birth:
-
Month
-
Day
Year
Age:
Gender (The gender your insurance company has on file)
Male
Female
Preferred pronouns
SSN:
*
Marital Status:
Single
Partnered
Married
Separated
Divorced
Widowed
Are you a registered sex offender? Or do you have any active or pending charges against a minor? *Please note that your answer may not preclude you from receiving mental or behavioral health services, but may limit the location in which you receive services.
*
Yes
No
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PARENT/LEGAL GUARDIAN
(If the client is a MINOR) Legal guardian must sign consent for treatment and all releases.
Is the client a minor?
*
Yes
No
GUARANTOR
(If the client is a MINOR or if the guarantor is someone other than the adult client) The financially responsible party.
Name:
First Name
Last Name
Relationship:
DOB:
-
Month
-
Day
Year
Date
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Please enter a valid phone number.
SSN:
*
Guardian 1
Name:
First Name
Last Name
Relationship to Client:
Phone:
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Guardian 2
Name:
First Name
Last Name
Relationship to Client:
Phone:
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
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EMERGENCY CONTACT
(Contacted ONLY if there is a medical or mental health emergency.) Person to reach if a minor’s parent/guardian cannot be contacted.
Name:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Relationship:
*
Other Information
Who referred you?
School (if client is a minor):
Is the client currently under a committal or was recently committed?
*
Yes
No
Please list date(s)
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INSURANCE
(PRIMARY)
Company:
*
Member ID:
*
Group #:
*
Policy Holder:
*
Policy Holder DOB:
*
-
Month
-
Day
Year
Date
Your Relationship to the Subscriber
*
Please Select
Self
Child
Spouse
Life Partner
Employee
Unknown
Other
Please select Insurance Type
*
Please Select
Blue Cross Blue Shield
United Health Care
Iowa Medicaid - Amerigroup
Iowa Medicaid - Iowa Total Care
Iowa Medicare
Health Partners
Private Pay
Other
Please Type
*
Policy Holder Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Insurance Card (front and back)
Browse Files
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Do you have a secondary insurance?
*
Yes
No
(SECONDARY)
Company:
*
Member ID:
*
Group #:
*
Policy Holder:
*
Policy Holder DOB:
*
-
Month
-
Day
Year
Date
Please select Insurance Type
*
Please Select
Blue Cross Blue Shield
United Health Care
Iowa Medicaid - Amerigroup
Iowa Medicaid - Iowa Total Care
Iowa Medicare
Health Partners
Private Pay
Other
Please Type
*
Policy Holder Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Insurance Card (front and back)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please verify that you are human
*
Save
Submit
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