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
Are You Requesting to See a Specific Counselor or Nurse Practitioner? If so, Please Put Their Name Here:
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
Aetna OhioRISE
AIM Academy @ Belden (CCSD)
Akron Children's Hospital
Alliance Elementary School
Alliance High School
Alliance High School (Career Tech)
Alliance Intermediate School
Alliance Middle School
Arts Academy @ Summit (CCSD)
Belmont Pines Hospital
Boardman Center Intermediate School
Boardman City Schools Online
Boardman Elementary - Robinwood Lane
Boardman Elementary - Stadium
Boardman Elementary - West Blvd
Boardman Glenwood Junior High School
Boardman Glenwood Junior High School (BRYT Program)
Boardman High School
Broadway Academy at Mount Pleasant (ACCEL)
Broadway Academy at Willow (ACCEL)
Cadence Care Network - OhioRISE CME
Canton Central Catholic High School
Canton College Preparatory School (ACCEL)
Canton Local School District
Cedar Elementary School (CCSD)
Cherrie Turner Tower
Choices High School (CCSD)
Clarendon Intermediate School (CCSD)
Coleman Health Services
Coleman Health Services - OhioRISE CME
Compton (Passages) Learning Center (CCSD)
Crenshaw Middle School (CCSD)
Early College @ Lehman (CCSD)
Early Learning Center @ Schreiber (CCSD)
Fairless Local School District
Fairmount Learning Center (CCSD)
Gibbs Elementary School (CCSD)
Harter Elementary School (CCSD)
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)
Hope Center - Boardman
Hope Center - Warren
Heritage Christian School (CCSD)
Integrated Behavioral Health Services - OhioRISE CME
Jefferson Co. Educational Services Center - OhioRISE CME
Louisville Elementary School
Louisville High School
Louisville Middle School
Louisville North Nimishillen Elementary School
Malone University
Marlington Local School District
Massillon City School District
McGregor Intermediate School (CCSD)
McKinley High School (CCSD)
North Canton City School District
Northwest School District
Ohio Guidestone - OhioRISE CME
Orange City Schools
Orange High School
Orange- Moreland Hills Elementary
Patrick Elementary School (CCSD)
Perry Local School District
Plain Local School District
Poland City Schools
Portage Collaborative Montessori (CCSD)
Portage Path Behavioral Health
Positive Education Program - OhioRISE CME
Ravenwood Health - OhioRISE CME
Red Oak Behavioral Health
Refuge of Hope
Saint Thomas Aquinas Middle/High School
Sebring Local School District
Shipley Pediatrics
Southeast Elementary School
Southeast Intermediate School
Southeast Middle School
Southeast High School
St. Joan of Arc Catholic School
St. Paul Catholic School
St. Peter School
Stark County Board of Developmental Disabilities
Stark County Court of Common Pleas
Stark County Family Court
Stark County Job and Family Services (CPS)
Stark County Probate Court
STEAM Academy of Warrensville (ACCEL)
STEAMM Academy @ Hartford (CCSD)
Stone Elementary School (CCSD)
Summit County Board of Developmental Disabilities
Summit County Children Services
Summit County Common Pleas Court
Summit County Domestic Relations Court
Summit County Job and Family Services (CPS)
Summit County Probate Court
Summit Psychological Associates
Tallmadge Middle School
UH Ulrich Professional Group
West Branch Digital Academy
West Branch Early Learning Center
West Branch High School
West Branch Middle School
West Branch Preschool
West Park Bilingual Academy (ACCEL)
Wingspan Care Group - OhioRISE CME
Worley Elementary School (CCSD)
Wright Preparatory Academy (ACCEL)
Youtz Intermediate School (CCSD)
OTHER - Not in List
School Name
*
Client Preference for Location of Treatment -- Select All That Apply
*
School
In Office (North Canton)
In Home
Telehealth
Community
Other
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
MedBen
OhioRISE Medicaid
OSCAR Health
SummaCare
Traditional Medicare Part B
Traditional Ohio Medicaid
TriCare
United Healthcare Commercial
UMR
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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