2025 Best Point's Online Referral Form

Online Referral Form
If you happen to need assistance with this form, please contact Best Point's Centralized Intake Department at (513) 272-2800.
Date of Referral

MonthDayYear
Date
Was permission from parent/guardian of the child received?*

YesNo
NOTE: permission from the child's parent or guardian must be obtained before submitting this referral to Best Point.
Person Making Referral*

First NameLast Name
Referrer's Phone Number*
Referrer's Email Address
Referring Entity*
Name of school, clinic, hospital, agency, etc.; if the parent/guardian is making the referral, enter “Self”

Parent/Guardian Information
Does the County have custody of the child?*

YesNoUnknown
If yes, which county has custody?
Parent/Guardian/JFS Worker Name*

First NameLast Name
Guardian relationship to Child (Note: If custody is not with biological parent or JFS custody paperwork will be needed before services can begin.)*
Primary Phone Number*
Parent/Guardian Email Address
Parent/Guardian have the same address as child
Parent/Guardian Street Address

Street Address

Street Address Line 2

CityState

Zip Code
Secondary Parent/Guardian Name

First NameLast Name
Relationship to Child
Secondary Primary Phone Number
Secondary Parent/Guardian Email
Secondary Parent/Guardian have the same address as child
Secondary Parent/Guardian Street Address

Street Address

Street Address Line 2

CityState

Zip Code

Insurance Information
What type of insurance does the child have?*

MedicaidCommercialBoth Medicaid and CommercialUnknown
Select Medicaid Plan
Medicaid Number (MMIS)
12 digits
Commercial Insurance Provider
Policy Number
Group Number
Name of Policy Holder

First NameLast Name
Policy Holder's Date of Birth

MonthDayYear
Policy Holder's Relationship to Child

Online Referral Form