Behavioral Health Referral Form
Referral Source Information
Service Provider Information
*
First Name
Last Name
*
Please Select
MD
CRNP
APRN
PA-C
Psychologist
LCPC
LCMFT
LCPAT
LCADC
LCSW-C
LGPC
LGMFT
LGPAT
LGADC
CPC-AD
CAC-AD
CSC-AD
ADT
RPS
CPRS
LCSW
LMSW
LBSW
OT/L
MT-BC
CRC
CPRP
CFRP
Case Manager
Probation Agent
Parole Officer
Intern/Extern
None of these
Other
Credentials
Organization Name
*
Address
*
Phone Number
*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email
*
Is Individual aware of this Referral?
*
Yes
No
Client Information
First Name
*
Last Name
*
Date of Birth
*
/
Month
/
Day
Year
Social Security Number
Individual Gender
*
Male
Female
Other
Individual Primary Language
*
English
Spanish
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
Program/Services client is receiving by provider:
Parent/Guardian Information (If Under 18)
Parent/Guardian Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Email
Insurance Information
Do the individual have insurance?
*
Yes
No
Out of Pocket
Policyholder’s Name
Insurance Company
Member ID
Group Number
Presenting Problem
Reason for Seeking Treatment/ Diagnosis (If applicable)
*
Current Medications
Please use the following for any additional pertinent information, special requests or patient expectations:
Select all applicable challenges below for the Individual referred (check all that apply)
*
Ability to avoid dangers/hazards
Anger
Anxiety
Daily living skills
Depression
Grief
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Phobias
Psychiatric Hospital Discharge
School behavior
Self Harm
Separation Issues
Social Skills
Mental Health & Substance Use
Sustainable employment
Trauma
Whole Health/Wellness
Youth to Young Adult Transition
Other
Upload Release of Information (ROI)
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Signature
*
Date of Referral
*
/
Month
/
Day
Year
Date
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