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Request for Services
Common Threads Family Resource Center
Client Demographic Information
This form is compliant with HIPPA regulations.
Client's Legal Name
*
First Name
Last Name
Preferred Name (If Applicable)
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Current Date
*
-
Month
-
Day
Year
Date
Your Age
Client Gender Assigned at Birth
*
Client's Pronouns
*
Ex: she/her, they/them, he/him, etc.
Client Phone Number
Client Email
Client Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client is under 18 or is 18+ with a legal guardian
Yes
Guardian's Name
First Name
Last Name
Guardian Email Address
example@example.com
Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please upload a copy of the guardianship documentation.
*
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Client Funding Information
Does this client have CCS? (Dane County CCS Only - Not Applicable to Insurance Clients)
Yes
CCS Service Facilitator Name
First Name
Last Name
CCS Service Facilitator Email
example@example.com
CCS Service Facilitator Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Please upload a picture of the front and back of your insurance card.
*
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WE ACCEPT: Aetna; Anthem; BCBS; BCBS Managed Care; Dane County CCS; Dean Health Plan; Dean Health Managed Care; Group Health Cooperative of South Central WI (GHC-SCW); Group Health Cooperative of South Central WI (GHC-SCW) Managed Care; Quartz HMO; Quartz PPO; and Quartz Managed Care. We accept Medicaid WI (Wisconsin) on a case-by-case basis (call or email for details). FOR NEUROPSYCHOLOGICAL EVALUATIONS WE ONLY ACCEPT: Quartz, Anthem, Group Health Cooperative of South Central WI (GHC-SCW), Forward Health (MA), and Dane County CCS.
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Service Request
Please Note: We have temporarily stopped accepting occupational therapy referrals as our waitlist has reached its capacity. Please follow us on social media or sign up for our newsletter to be notified when we open the waitlist up again.
What services are desired?
*
Mental Health Counseling/Psychotherapy
Speech Therapy
Psychoeducation or Parent Coaching
Neuropsychological Evaluation
Per CCS guidelines, each client can have only one ISD provider per organization or location. Which service would you like to prioritize for the waitlist at this site?
*
Occupational Therapy
Speech Therapy
Neuropsychological Evaluation Eligibility Screening Questions
The following questions help us determine whether the requested service is appropriate and whether we are able to meet your needs. Please answer to the best of your ability.
Is the client currently involved in active legal proceedings? (Examples: divorce, child custody, guardianship, probation, parole, etc.)
*
Yes
No
Is the client experiencing active addiction? (Includes history of sex addiction.)
*
Yes
No
Is the client at least 60 days sober?
*
Yes
No
Does the client have a history of brain injury, dementia, or seizure disorders?
*
Yes
No
Is the client seeking this service for worker’s compensation, fitness-for-duty, forensic evaluation, or court-mandated purposes?
*
Yes
No
Is the client unable to access testing processes due to blindness or deafness?
*
Yes
No
Previous Diagnoses (if known)
*
Reason for Referral
*
What is the client's best availability for services?
*
Questions? Give us a call at (608) 838-8999 or email us at info@commonthreadsmadison.org!
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