Provider Referral Form
Thank you for thinking of Born to Blossom Behavioral Therapy for your client's mental healthcare needs. Please complete the provider referral form and we will be in contact them within 48 business hours. Attach any supporting documentation (e.g., medical records, IEP/504 plans) if applicable.
Client information
Client Name
*
First Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Date
Client Gender
*
Please Select
Male
Female
Non-Binary
Unsure
Client Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name (If applicable)
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Client's Insurance Provider
*
Please Select
Aetna Better Health of Oklahoma (OK Medicaid)
Blue Cross Blue Shield (BCBS)
Healthy Blue (KS Medicaid)
Humana Healthy Horizons of Oklahoma (OK Medicaid)
Oklahoma Complete Health (OK Medicaid)
Sunflower Better Health (KS Medicaid)
United Healthcare Better Health (KS Medicaid)
Other (Client would be Out of Network)
Supporting Information
Diagnosis (if applicable):
*
Reason for Referral
*
Please Select
ABA Therapy
Autism Diagnostic Evaluation
Talk Therapy
Parent Coaching
Brief Description of Client Needs or Concerns
*
Is the client currently receiving other services?
*
Please Select
Yes
No
Unsure
Does the client have an Individualized Education Plan (IEP) or 504 plan?
*
Please Select
Yes
No
Unsure
Attach IEP/504 Here.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Attach Supplemental Medical Documentation Here.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Provider Information
Referring Provider Name
*
First Name
Last Name
Practice/Organization Name
*
Practice Phone Number
*
Please enter a valid phone number.
Practice Fax Number
*
Please enter a valid phone number.
Practice/Organization Email Contact
*
Preferred Contact Method for Follow-Up
*
Please Select
Phone
Email
Fax
Questions or Concerns?
Our intake team is available to assist at 620-330-9036 or onboarding@borntoblossomaba.com.
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