OP MH Referral Form

Outpatient Clinic-Based Services Referral Form
This form can be completed by the youth's provider, case worker or other community partner. This referral form is to establish Level B/C clinic-based services for a child/youth at one of our clinics.

This is not a referral for Community Based Services (Level D): If you are seeking Community-Based Services for a youth, please contact the youth's Behavioral Health Insurance Provider to determine eligibility and referral/authorization requirements. Our community-based services require a referral from a current mental health provider and are only available for select insurance plans.
Youth's Information:

Please provide the following demographic and other identifying information about the youth.
Youth's Legal Name:

First Name Last Name
Youth's Preferred Name:
Date of Birth:

MonthDayYear
Youth's Sex Assigned at Birth:
Youth's Gender Identity:
Youth's Pronouns:
Youth's Race/Ethnicity:
Youth's Ethnicity:
Does the youth have their own phone number?
Youth's Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Does the youth have their own email?
Youth's Email:
example@example.com
Youth's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Legal Guardian/Caregiver Information:

Please provide the youth's legal guardian/caregiver information.
Legal Guardian Name:

First Name Last Name
Legal Guardian Relationship to the Youth:
Legal Guardian Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Legal Guardian Email:
Please enter a valid email address.
Is the Legal Guardian also the youth's Primary Caregiver? (The adult who the youth lives with and/or who takes care of the youth full-time or most of the time)
Primary Caregiver:

First NameLast Name
Primary Caregiver's Relationship to Youth:
Primary Caregiver Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Primary Caregiver Email:
example@example.com
Is the youth in DHS or OYA custody?
Select if True:
*Please note: A signed Release of Information (ROI) will need to be obtained from the youth's legal guardian or youth (if 14 years or older) for any other invididual(s) involved in services with the exception of other current providers.**

Language and interpreter Services:

If the youth or youth's family will need interpreter services, please indicate what language and/or what type of interpreter services will be needed, including ASL (sign language)
What is the youth's preferred language?
What is the primary language spoken in the home?
Will interpreter services be needed to contact the family or the youth?
Type of Interpreter Services
Insurance Information:

Please provide the youth's insurance information. We accept the following insurance providers. We do not accept out-of-network or out-of-pocket pay.
Insurance Provider:
Medical Identification Number:
Policy Holder Name:
If Commercial Insurance

Referral Information:

Please provide the reason for requesting services and primary contact for scheduling.
Reason for Requesting Services:
Briefly describe what led to this referral/request for services (i.e. family conflict, trauma/loss, life stressors, social/emotional/behavioral concerns, etc.).
Primary Contact for Screening and Scheduling:
Name of Primary Contact:
Unless primary contact is youth.
Primary Contact's Relationship to Youth:
If Other
Primary Contact's Phone Number:
If Other: Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact Email:
If Other: Please provide a valid email address
Location Requested for Services:

Please provide the preferred location(s) for services. If you select more than one location, please select and indicate your top preference in the 'Top Preference if more than one location is selected' field.
Morrison Site Requested:

Top Preference if more than one location is selected:
Additional Information
Please provide any additional information that would be helpful for our intake team to know.
Referring Individual: (Name of person completing this form)

First NameLast Name
Referring Individual's Relationship to the Youth:
Referring Individual's Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Referring Individual's Email:
example@example.com
Referring Agency:
Please include any documents you believe would be beneficial for the therapist to review:

Cancelof
Should be Empty:

Outpatient Clinic-Based Services Referral Form