Responsive Centers New Referral Form

Referral 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.
Please Note: Our intake staff respond to inquiries during business hours only.

We will make every effort to honor your clinician preferences (e.g., Preferred Age, Gender, Specific Clinician Name, Specialty). 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.
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
Date
Client's Email*
example@example.com
Client's Mobile Number*
Does the client agree to receive SMS messages at the phone number listed above?

Yes, client agrees.
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/. 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
Clinician Preferences
Preferred Age, Gender, Specific Clinician Name, Specialty, etc.
Schedule Appointment By

MonthDayYear
Discharge Date, Following Crisis Evaluation, etc.
Client is seeking:*

Counseling/PsychotherapyPsychiatric Medication ManagementKetamine Therapy (e.g., Spravato)Testing/Assessment Services
Counseling/Psychotherapy Services

Individual TherapyPlay TherapyCouples CounselingFamily Therapy
Psychiatric Medication Management Services

Psychiatric MedicationPsychiatric Evaluation
Testing/Assessment Services

ADHD EvaluationAutism EvaluationAcademic TestingPsychological AssessmentCognitive Testing
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
Date

MonthDayYear
Today's Date
Signature

Clear
Should be Empty:

Referral For Outpatient Services

General Information

Services Requested

HIPAA Acknowledgement