Provider/Agency Referral Form

Provider/Agency Referral Form
Currently, we are only accepting clients for telehealth services.

NOTE: "CLIENT" refers to the specific individual who will be receiving services, NOT the parent, guardian, or authorized representative. Please ensure that all fields marked with an asterisk (*) are completed.
- Name of Referring Provider:
  Please include your credential(s) if applicable
- Source of Referral:
- Agency/Practice Name:
- Agency/Practice Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Phone Number:
  Please enter a valid phone number.Format: (000) 000-0000.
- Fax Number:
  Please enter a valid phone number.Format: (000) 000-0000.
- Email:
- Client Name:
- Date of Birth:
  
  MonthDayYear
- Social Security Number (if known):
- Sex Assigned at Birth:
- Current Living Situation:
- Home Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Home Phone
  Format: (000) 000-0000.
- Cell Phone
  Format: (000) 000-0000.
- Email:
- Preferred Contact Method:
  
  Other
- Parent/Guardian Name:
- Relationship with Client:
- Home Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Home Phone:
  Format: (000) 000-0000.
- Cell Phone:
  Format: (000) 000-0000.
- Email:
- Preferred Contact Method:
  
  Other
- For clients being referred for gambling treatment, please note that services are provided at no cost to the individual. Please select “Problem Gambling Reimbursement Program” as the Method of Payment for Treatment and select “Not Applicable” for the Insurance Carrier.
- Method of Payment for Treatment:
- Insurance Carrier:
- Member ID:
- Group Name:
- Policy Holder:
- Briefly describe the reason for the referral and the client’s presenting concerns. Include or attach any relevant medical or mental health diagnosis, or social information that might assist in treatment planning.
- Type of Services Requesting:
  
  Other
- To ensure a timely intake, please attach the following documents::
  - A signed Release of Information (ROI) from the client
  - A copy of the client’s government-issued identification card
  - A copy of the client’s insurance card (Front & Back)
  - Any supporting documents that may assist with the individual’s requested treatment (e.g., recent evaluations, discharge summaries, treatment history, court orders, case plans, etc.)
  This is optional; however, a signed ROI will be required if you would like to receive treatment updates or have us coordinate services.
- Cancelof
- Signature
- Date
  
  MonthDayYear
- Should be Empty: