Provider/Patient Referral Form JWC LLC Bloom

Referral Enrollment Form

JADE Wellness Center LLC
Referring To:

JADE Wellness Center (Drug & Alcohol Treatment)Bloom Mental Health ServicesJohn Ryan's House (Recovery Housing)AIMS (Accessing Immediate Opioid Use Disorder Medication)John's EchoOther
Are you a referring provider or an individual seeking service?

Provider ReferralPatient/Individual Seeking Services
Provider Organization/Agency
Provider Referral Name

First NameLast Name
Provider Phone
Please enter a valid phone number.Format: (000) 000-0000.
Provider E-Mail Address
example@example.com
Provider Fax
Please enter a valid fax number.Format: (000) 000-0000.
Confirm with me when patient is contacted:

Yes (Please provide secure email or fax for confirmation)No
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Patient Phone Number:
Format: (000) 000-0000.
Patient E-mail
example@example.com
Insurance Name:
Provide Name of Insurance Above
Member ID:
Which primary location is this referral for?

WexfordMonroevilleSoutshideBrooklineTelehealthUnsure/NA
What services is the client receiving from you?

Therapy/CounselingGroup CounselingPrimary CareAddiction TreatmentOther
How long has the client been receiving services from you?
Services of Interest

Outpatient TherapyIndividual CounselingIntensive Outpatient ServicesPsychiatric Medication ManagementMedication Assisted TreatmentRecovery HousingCertified Recovery SpecialistsOther
How can we help?
Briefly describe your patient's needs
Thank you
By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold JADE Wellness Center LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.**

Yes
Should be Empty:

Referral Enrollment Form