Outpatient Referral Form
This form is to submit a referral to HWS Best Health Counseling for our various service lines including counseling/psychotherapy, case management and medication management.
Client Information
Referral Date
*
-
Month
-
Day
Year
Date
Is Client a Minor? (Under 18 yo. or Has a Court Appointed Legal Guardian)
*
Please Select
Yes
No
Full Name of Client
*
First Name
Last Name
Preferred Name (if applicable)
Reason for Referral
*
Services Requested - Select All That Apply
*
Counseling/Therapy
Case Management
Medication Management/Psychiatry
Other
Level of Referral Urgency
*
Not Urgent
1
2
3
4
Extremely Urgent
5
1 is Not Urgent, 5 is Extremely Urgent
Is This Referral Being Made By An Agency or Organization?
*
No - I am submitting the referral for myself or for my child
Yes - This referral is being submitted by an agency or organization on behalf of the client
Referring Agency/Organization
*
Please Select
OTHER - Not In List
HWS Staff Member
Aetna OhioRISE
AIM Academy@ Belden
Akron Childrens Hospital
Alliance Elementary School
Alliance High School
Alliance High School (Career Tech)
Alliance Intermediate School
Alliance Middle School
Arts Academy @ Summit
Belmont Pines Hospital
Boardman Center Intermediate School
Boardman City Schools Online
Boardman Elementary - West Blvd
Boardman Elementary - Stadium
Boardman Elementary - Robinwood Lane
Boardman Glenwood Junior High School
Boardman High School
Broadway Academy
Bulldog Virtual Academy
Cadence Care Network - OhioRISE CME
Canton City Schools
Canton-Mckinely Senior High School
Cedar Elementary School
Cherrie Turner Tower
Choices
Clarendon Intermediate School
Coleman Health Services
Coleman Health Services - OhioRISE CME
Crenshaw Middle School
Early College @ Lehman
Early Leaming Center @ Schreiber
Fairmount Learning Center
Gibbs Elementary School
Harter Elementary School
Head Start - Allstar Kids (Canton)
Head Start - Fairplay (Massillon)
Head Start - Franklin (Alliance)
Head Start - JRC (Canton)
Head Start - Malloy (Massillon)
Head Start - Southeast (SE Canton)
Head Start - William Hunter (Canton)
Integrated Behavioral Health Services - OhioRISE CME
Jefferson Co. Educational Services Center - OhioRISE CME
Louisville City Schools
Louisville Elementary School
Louisville High School
Louisville Middle School
Louisville Nimishillen Elementary School
Manor Avenue Elementary School
McGregor Intermediate School
McKinley High School
Ohio Guidestone - OhioRISE CME
Orange City Schools
Orange High School
Orange- Moreland Hills Elementary
Passages High School
Patrick Elementary School
Poland City Schools
Poland-Mckinely Elementary
Portage Collaborative Montessori
Portage Path Behavioral Health
Positive Education Program - OhioRISE CME
Ravenwood Health - OhioRISE CME
Red Oak Behavioral Health
Refuge of Hope
Shipley Pediatrics
Stark County Board of Developmental Disabilities
Stark County Children Services
Stark County Court of Common Pleas
Stark County Family Court
Stark County Job and Family Services
Stark County Probate Court
STEAM Academy (Warrensville)
STEAMM Academy@ Hartford
Stone Elementary School
Summit County Board of Developmental Disabilities
Summit County Children Services
Summit County Common Pleas Court
Summit County Domestic Relations Court
Summit County JFS
Summit County Job and Family Services
Summit County Probate Court
Summit Psychological Associates
Tallmadge Middle School
West Branch Digital Academy
West Branch Early Learning Center
West Branch High School
West Branch Middle School
West Branch Preschool
Wingspan Care Group - OhioRISE CME
Worley Elementary School
Wright Preparatory Academy
Youtz Intermediate School
Client Preference for Location of Treatment -- Select All That Apply
*
School
In Office (North Canton)
In Home
Telehealth
Community
Other
School Name
*
Gender Preference of Provider
*
Male
Female
No Preference
Other
Demographics
Sex Assigned at Birth
*
Male
Female
Gender Identity
Cis (natural born) Male
Cis (natural born) Female
Trans Woman
Trans Man
Non-binary
Other
Sexual Orientation
Straight
Gay/Homosexual
Bisexual
Other
Client's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Client's Social Security Number
Client's Phone Number
*
Please enter a valid phone number.
Client's Email Address
example@example.com
Parent/Guardian Contact Information
Parent/Guardian's Name
*
First Name
Last Name
Parent/Guardian's Phone Number
*
Please enter a valid phone number.
Parent/Guardian's Email Address
Providing this will reduce referral wait times
Check Here if Parent/Guardian's Address is the Same as the Clients
*
Same Address
Parent/Guardian's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Information
Client's Insurance Company
*
Please Select
UNINSURED
INSURANCE UNKNOWN
OTHER INSURANCE NOT LISTED
Aetna Commercial
Aetna Medicare
AmeriHealth Medicaid
Anthem Commercial
Anthem Medicaid
Anthem Medicare
AultCare
Buckeye Marketplace
Buckeye Medicaid
Buckeye Medicare
CareSource Marketplace
CareSource Medicaid
CareSource Medicare
Cigna Commercial
Humana Medicaid
Humana Medicare
Medical Mutual Commercial
Molina Marketplace
Molina Mdicare
Molina Medicaid
OhioRISE Medicaid
SummaCare
Traditional Medicare Part B
Traditional Ohio Medicaid
TriCare
United Healthcare Commercial
United Healthcare Medicaid
United Healthcare Medicare
Client's Insurance Policy/ID #
Client's Insurance Card
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Referring Organization Information
Additional Notes / Things We Should Be Aware of
Name of Referring Individual
*
First Name
Last Name
Title of Referring Individual
*
ie. Social Worker, Principal, Primary Care Doctor, etc.
Phone Number of Referring Individual
*
Please enter a valid phone number.
Email Address of Referring Individual
*
example@example.com
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