Behavioral Health Self Referral Form

Behavioral Health Self Referral Form

This form is intended for individuals who wish to refer themselves or someone else to Bleuler Psychotherapy Center. It can be used by family members, friends, or anyone who knows the person seeking help.
Instructions: Please complete this form with as much detail as possible. Accurate and thorough information will help us provide the best possible care.
Who is this referral for?*

SelfOther
Please provide your information, if you are making this referral for someone else.
Referral Source Name *

First NameLast Name
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Your relationship to the person in need of services*

SpouseChildParentSiblingFriendStudentOther
Please provide the information below for the person you are referring.
Name*

First NameLast Name
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Primary language*
Date of birth*

MonthDayYear
Age
Gender

MaleFemalePrefer not to sayOther
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is individual aware of this referral?*

YesNo
Parent/Guardian Name*

First NameLast NameRelationship
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Specify services being considered (select all that apply)

Individual TherapyCouples TherapyFamily TherapyGroup TherapyMedication ManagementMedication Assisted TreatmentSubstance Use Services
Preferred platform for treatment*

Virtual / TelehealthIn personNoneUnknown
Please describe the main reason(s) for seeking services at Bleuler Psychotherapy Center. Include any specific issues, symptoms, or concerns that you or the individual being referred are currently experiencing.
Are you or the individual being referred currently being prescribed any psychotropic medication?*

YesNoUnknown
List current psychotropic medications
Date

MonthDayYear
Upload your insurance card (optional)

Cancelof
Upload your ID (optional)

Driver's license, etc.
Cancelof
Upload any relevant clinical documentation (optional)

List of medication, prior therapy record, etc.
Cancelof
Please verify that you are human*
Should be Empty:

Behavioral Health Self Referral Form

Please provide your information, if you are making this referral for someone else.

Please provide the information below for the person you are referring.