Positive Leaps
Internal Intake/Referral Form
Type
Call
Referral
Call Source
Referral Source
Patient Information
Child's First and Last Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's Gender
*
Male
Female
Is the child Hispanic or Latino?
*
No
Yes
Child's Race
*
Caucasian
Black/African-American
Alaskan/Native American
Indian
Asian
Other
Parent/Guardian Contact Information
Required
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian to Child
*
Child Relationship to Parent/Guardian
*
Biological Child
Foster Child
Grandchild
Other
Parent/Guardian's Primary Language
*
Please Select
English
Mandarin Chinese
Hindi
Spanish
Standard Arabic
French
Bengali
Portuguese
Russian
Indonesian
Urdu
Standard German
Japanese
Nigerian Pidgin
Egyptian Arabic
Marathi
Vietnamese
Telugu
Hausa
Turkish
Alternate Contact (English Speaking)
"Who may we speak with if parent's native language is not English?"
Primary Contact Number
*
Format: (000) 000-0000.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Is there an additional contact to add?
*
Yes
No
Additional Contact Information
Optional
Additional Contact Name
First Name
Last Name
Additional Contact Phone
Format: (000) 000-0000.
Does the family have a caseworker?
*
Yes
No
Caseworker Information
Caseworker Name
First Name
Last Name
Caseworker Phone
Format: (000) 000-0000.
Caseworker Email
example@example.com
Provider Information
Referring Facility/Office Name
Name of the facility/office referring the patient.
Provider Name
First Name
Last Name
Suffix
Office Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Office Fax
Please enter a valid fax number.
Format: (000) 000-0000.
Does the child have insurance coverage?
Commercial/Employer/Marketplace
Medicaid
No Coverage
Primary Insurance Information
Primary Insurance Name
Member ID Number
Is there a secondary insurance policy to add?
Yes
No
Secondary Insurance Information
Insurance Name
Member ID Number
Does your child have Medicaid coverage?
Yes
No
Medicaid Insurance Information
Medicaid Carrier Name
Please Select
Aetna OhioRISE
AmeriHealth Caritas
Anthem BCBS Community Plan
Buckeye Health Plan
CareSource
Humana Healthy Horizons
Molina HealthCare
UnitedHealthcare Community Plan
Member ID Number
Plan ID Number
CareSource Plans Only
Office Use Only
Recommended Treatment Plan
Intensive Outpatient Program (IOP; Part-time day treatment)
Outpatient Program (OP Therapy)
Partial Hospitalization Program (PHP; Regular day treatment)
Add to Waitlist
True
False
Insurance Coverage Verified
Yes
No
Medicaid Coverage Verified
Yes
No
Not Applicable
Tour Scheduled
Yes
No
Virtual
Tour Date/Time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Assessment Scheduled
Yes
No
Assessment Date/Time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date and Time of Review of Referral Form
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Completing Staff Member
*
Please Select
Bridget Smith
Laura Elmlinger
Valerie Edwards
Jess Lukas
Submit
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