Behavioral Health Referral Form

Behavioral Health Referral Form

Individual Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Email
example@example.com
Primary Language
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Individual aware of this Referral?

YesNo
Referral Source

Ada S McKinleyInsuranceIMANDCFSRiveredge HospitalHospital ERSASSGarfield ParkOther
Insurance Coverage*

Blue Cross Community OptionBlue Cross PPOAetnaCignaCounty CareUnited HealthcareStraight MedicaidMedicare
Group ID
Member ID
Type of Services Needed

AdultChildAdolescent
School Name
Parent/Guardian Name

First NameLast NameRelationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Specify service Individual is considering

Individual TherapyFamily TherapyPathways ProgramCouples TherapyCommunity SupportMental Health Consulting ServicesOther
Specify service Individual is considering

Individual TherapyFamily TherapyPathways ProgramCouples TherapyCommunity SupportMental Health Consulting ServicesOther
Individual Gender

MaleFemaleNon-binaryOther
Individual Primary Language

EnglishSpanishOther
Reason for Referral
Select all applicable challenges below for the Individual referred (check all that apply)

Ability to avoid dangers/hazardsAngerAnxietyCommunity Linkage of ServicesDaily living skillsDepressionGriefHousing in StabilityHygieneImpulsive BehaviorsJuvenile Justice/Court InvolvedLife SkillsMaintaining personal affairsNutritionalPhobia/sHospital Discharge/Collaboration PlanningSafe living situationSchool behaviorSelf-Advocacy SkillsSelf HarmSeparation IssuesSocial SkillsSubstance UseSustainable employmentTraumaTruancyWhole Health/WellnessYouth to Young Adult TransitionPTSD AssessmentSexual DisfunctionPornography Addiction AssessmentLife Skills AssessmentOther
Should be Empty: