Referral Request [RC]

Refer a Client for Outpatient Services

At Responsive Centers, we are experienced in guiding individuals through healing and recovery with empathy and expertise. Referred clients benefit from our commitment to comprehensive, personalized care and a community-centered approach to mental wellness. Make the first step simple – complete the referral form today to get them connected to support.
Looking to schedule a follow-up? You may submit a next appointment request on behalf of the client if they are already seeing a clinician for the desired service.

Please Note: Our intake staff respond to inquiries during business hours only.
Are you the client?
Name of Referrer

First NameLast Name
Relationship to Client
Provider, Caregiver, Teacher, Guidance Counselor, etc.
Referring Organization
Hospital, Facility, School, Independent Clinic, etc. –– if you are a Caregiver, Parent, etc., please write "N/A" here.
Referrer's Email
Please enter your email address where we can contact you regarding this referral request, as needed.
General Information
Client's Name

First NameLast Name
Client's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client's Email
example@example.com
Client's Mobile Number
Format: (000) 000-0000.
Does the client agree to receive SMS messages at the phone number listed above?
By checking this box, you consent to receive text messages from Responsive Centers regarding your inquiries, orders, or services. You may opt-out at any time by replying STOP. For assistance, text HELP or review our Privacy Policy: https://responsivecenters.com/privacy-policy.php. Message and data rates may apply. Messaging frequency may vary. By checking this box, you acknowledge that you have read and understood our Privacy Policy and the terms and conditions written here. For better communication, scheduling, and completing paperwork, we recommend clients consent to receiving text messages from Responsive Centers.
Payment Type
Choose Insurance or Self-Pay
Insurance Provider
Other Provider
If selected 'Other', include the name of the Client's Insurance Provider
Member ID/EAP Auth. #
Policy Holder's Relationship to Client
Policy Holder's Gender
Insurance Card (Front)
Insurance Card (Back)
Services Requested

We will make every effort to honor your preferences. However, prior to scheduling your appointment, we will verify insurance/billing details, check clinicians' schedules, and determine the level of urgency, along with other factors, to guarantee a seamless and efficient intake process.
Clinician Preferences
Preferred Age, Gender, Specific Clinician Name, Specialty, etc.
Schedule Appointment By

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDischarge Date, Following Crisis Evaluation, etc.
Client is being referred for:
Counseling/Psychotherapy Services
Psychiatric Medication Management Services
Testing/Assessment Services
Reason For Referral:
Diagnosis, Medical History, Specific Concerns, etc.
How did you hear about us?
Would you like to add any other information?
Please upload any relevant documents here.

If applicable, please include a Release of Information from the referral site.
Cancelof
HIPAA Acknowledgement

Clients have certain rights to privacy regarding their protected health information under the HIPAA Act. By checking the box above and submitting this form, the client is acknowledging that they may voluntarily be sharing sensitive information with our practice. While Responsive Centers cannot guarantee confidentially, we will never share any sensitive information with unknown third-party entities or use it for purposes outside of intake and scheduling. Please review our complete Privacy Policy here: https://responsivecenters.com/privacy-policy.php.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearToday's Date
Signature
Should be Empty:

Refer a Client for Outpatient Services

General Information

Services Requested

HIPAA Acknowledgement