Consumer Referral Form

Consumer Referral Form

Please fill out the following form to refer yourself or a consumer. All information provided will be handled in strict compliance with HIPAA regulations to ensure patient confidentiality and data security.
Consumer Full Name*

First NameLast Name
Consumer Email Address*
example@example.com
Date of Referral*

MonthDayYear
Date
Consumer's Home Address*

Street Address

Street Address Line 2
CityStateZip Code
Consumer's Mobile Phone Number (Enter 999-999-9999 if no Mobile Phone)*
Please enter a valid phone number.
Consumer's Home Phone Number (Enter 999-999-9999 if no Home Phone)*
Please enter a valid phone number.
Consumer's Date of Birth*

MonthDayYear
Date
Highest Level of Education
Choose one answer
Consumer's Marital Status

SingleMarriedSeparatedDivorced
Name of the Last School Attended
Consumer's Ethnicity

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOtherPrefer not to answer
Consumer's Gender

WomanManNon-BinaryTransgenderOtherPrefer not to answer
Upload Images for Consumer's Insurance Cards (including Medicaid) and Social Security Card

Cancelof
Consumer's Medicaid Number*
Ex., 999888777X
Consumer's Social Security Number*
Ex., 555-99-3333
Consumer's Emergency Contact Full Name*

First NameLast Name
Consumer's Emergency Contact Address*

Street Address

Street Address Line 2
CityStateZip Code
Consumer's Emergency Contact Phone/Mobile Number*
Please enter a valid phone number.
Consumer's Primary Care Doctor's Full Name*

First NameLast Name
Consumer's Primary Care Doctor's Location/Address*

Street Address

Street Address Line 2
CityStateZip Code
Weight
Ex., 198 pounds
Height
Ex., 5 feet 8 inches
List Consumer's Allergies*
List Consumer's Medications*
Consumer's Medical/Mental Health Diagnosis*
Family Medical History*
Ex., My Mother has diabetes
Services Requested (check all that apply)

Individual SupportSubstance Abuse Intensive Outpatient (SAIOP)Comprehensive Substance Abuse Treatment (SACOT)Outpatient TherapyPeer SupportOther
Reason for Consumer Referral (check all that apply)

Self ReferralLegal (Court, Probation, Parole, etc.)Treatment Accountability for Safer Communities (TASC)Other
Enter the Name of Who Referred You

First NameLast Name
Enter the Email of Who Referred You
example@example.com
Enter the Phone Number of Who Referred You
Please enter a valid phone number.
Enter the Place of Who Referred You
Example: Varick on 7th
Patient Data Privacy and Confidentiality Agreement*

I consent to the use and disclosure of my health information for treatment, payment, and healthcare operations as permitted by HIPAA.I understand that my information will be handled securely and in compliance with HIPAA regulations.
Provider Data Privacy and Confidentiality Agreement*

I confirm that the healthcare providers involved will handle the patient information in compliance with HIPAA.I acknowledge that all data will be stored and transmitted securely to protect patient confidentiality.
I agree to the terms and conditions regarding data privacy and HIPAA compliance.*
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