Referral Enrollment Form
JADE Wellness Center LLC
Referring To:
JADE Wellness Center (Drug & Alcohol Treatment)
Bloom Mental Health Services
John Ryan's House (Recovery Housing)
AIMS (Accessing Immediate Opioid Use Disorder Medication)
John's Echo
Other
Are you a referring provider or an individual seeking service?
Provider Referral
Patient/Individual Seeking Services
Provider Organization/Agency
Provider Referral Name
First Name
Last Name
Provider Phone
Please enter a valid phone number.
Provider E-Mail Address
example@example.com
Provider Fax
Please enter a valid fax number.
Confirm with me when patient is contacted:
Yes (Please provide secure email or fax for confirmation)
No
Patient's Name
First Name
Last Name
Date of Birth
Please select a month
January
February
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Month
Please select a day
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Day
Please select a year
2025
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Year
Patient Phone Number:
Patient E-mail
example@example.com
Insurance Name:
Provide Name of Insurance Above
Member ID:
Which primary location is this referral for?
Wexford
Monroeville
Soutshide
Brookline
Telehealth
Unsure/NA
What services is the client receiving from you?
Therapy/Counseling
Group Counseling
Primary Care
Addiction Treatment
Other
How long has the client been receiving services from you?
Services of Interest
Outpatient Therapy
Individual Counseling
Intensive Outpatient Services
Psychiatric Medication Management
Medication Assisted Treatment
Recovery Housing
Certified Recovery Specialists
Other
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
Enroll
Should be Empty: