Behavioral Health Referral Form
Individual Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Email
example@example.com
Primary Language
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Individual aware of this Referral?
Yes
No
Referral Source
Ada S McKinley
Insurance
IMAN
DCFS
Riveredge Hospital
Hospital ER
SASS
Garfield Park
Other
Insurance Coverage
*
Blue Cross Community Option
Blue Cross PPO
Aetna
Cigna
County Care
United Healthcare
Straight Medicaid
Medicare
Group ID
Member ID
Type of Services Needed
Adult
Child
Adolescent
School Name
Parent/Guardian Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Specify service Individual is considering
Individual Therapy
Family Therapy
Pathways Program
Couples Therapy
Community Support
Mental Health Consulting Services
Other
Specify service Individual is considering
Individual Therapy
Family Therapy
Pathways Program
Couples Therapy
Community Support
Mental Health Consulting Services
Other
Individual Gender
Male
Female
Non-binary
Other
Individual Primary Language
English
Spanish
Other
Reason for Referral
Select all applicable challenges below for the Individual referred (check all that apply)
Ability to avoid dangers/hazards
Anger
Anxiety
Community Linkage of Services
Daily living skills
Depression
Grief
Housing in Stability
Hygiene
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Maintaining personal affairs
Nutritional
Phobia/s
Hospital Discharge/Collaboration Planning
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Sustainable employment
Trauma
Truancy
Whole Health/Wellness
Youth to Young Adult Transition
PTSD Assessment
Sexual Disfunction
Pornography Addiction Assessment
Life Skills Assessment
Other
Submit
Should be Empty: