Franchise Therapy Referral Form

Our team schedules appointments three weeks prior to opening a clinic. If you are interested in scheduling with a different clinic, please check on our website for opening updates.

To make a referral for a new clinic opening within the next three weeks or that is already open, please complete the following form. A member of the Ellie team will be in touch within 1-3 business days.

For MN clinics, please click here.

Thanks!

In what State do you need services in? *

If you don't see your state listed here, we may not be ready to take clients in your state, just yet. Check this form out to see if we are coming to your state and to be notified when we are ready to schedule you! Look up other states

Choose an Illinois clinic/location *

Choose an STATE clinic/location *

Choose an Florida clinic/location *

Choose an Colorado clinic/location *

Choose an Arizona clinic/location *

Choose an Indiana clinic/location *

Choose a Tennessee clinic/location *

Choose a Texas clinic/location *

Choose a Michigan clinic/location *

Choose a Utah clinic/location *

Name *

First Name Last Name

Preferred Name

Pronouns

Sex

Phone Number *

Area Code Phone Number

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

County *

County

Date of Birth *

Date

Is this person under the age of 18? *

Are the parents/guardians of this person divorced or separated? *

Yes No

Parent/Guardian 1 Name *

Parent/Guardian 1 Email *

Parent/Guardian 1 Phone *

Parent/Guardian 2 Name

Parent/Guardian 2 Email

Parent/Guardian 2 Phone

What days/times work best? *

Would you like to use insurance? *

Insurance Company* *

Group Number *

ID Number *

Payer ID *

Often found on the back of insurance card!

Claims Address (often found on the back of insurance card) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Who is the policy holder for your insurance plan?

Self Relative

Policy holder’s relationship to you

(ie. parent, spouse, etc.)

Policy holder’s name (first and last)

Policy holder’s date of birth

Policy holder’s address

Same as Mine

Do you have a supplemental insurance plan?

Supplemental Insurance Company

Supplemental Insurance: Group Number

Supplemental Insurance: ID Number

Supplemental Payer ID *

Often found on the back of insurance card!

Supplemental Claims Address (often found on the back of insurance card) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Who is the policy holder for your supplemental insurance plan?

Self Relative

Supplemental Insurance Policy holder’s relationship to you

(ie. parent, spouse, etc.)

Supplemental insurance policy holder (First and Last name)

Supplemental insurance policy holder's DOB

Supplemental Policy Holder’s address

Are you following a provider who is moving to Ellie? *

If you are following a provider who is moving to Ellie, what is their name? *

Therapist Gender Preference *

Previous/Current Diagnosis (if applicable)

How do you prefer we contact you? *

Phone Email

Please write the name of the Provider who recommended us:

Please provide a brief summary describing your goals in therapy or the type of support you are seeking: *

0/100

How many Intake Assessments have you had in the current calendar year? *

If you are unsure, please enter "0"

Any additional information to help find a good match for a practitioner please write below:

As soon as we receive a referral, Ellie staff will begin processing and verifying insurance coverage. If a client has "inactive" insurance, we will not be able to schedule an intake until we have confirmed that insurance is active or the referral would like to proceed with cash pay options. Thank you for working with us. We appreciate the support and assistance in coordination.

Please verify that you are human *

How did you hear about us? *

Internet Search (Google) Friend or Family Member Another Provider (ie. Doctor, case manager) An online advertisement (Facebook/YouTube) Other Media (i.e. radio or TV) Newsletter At a Community Event (ie. resource fair, presentation)

Therapy Referral Form - Ellie Mental Health