Provider/Agency Referral Form

Provider/Agency Referral Form
At this time, we are only accepting referrals for telehealth services.

Referral Source Information
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.
Fax Number:
Please enter a valid phone number.
Email:*

Client Information
Client Name:*
Date of Birth:*

MonthDayYear
Social Security Number (if known):
Sex Assigned at Birth:*

MaleFemale
Current Living Situation:*
Home Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone
Cell Phone
Email:
Preferred Contact Method:

PhoneEmailOther

Parent/Guardian Information (for Minors)
Parent/Guardian Name:
Relationship with Client:
Home Address:

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone:
Cell Phone:
Email:
Preferred Contact Method:

PhoneEmailOther

Insurance Information
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:

SelfSpouseChildLife PartnerOther RelationshipUnknownNot Applicable

Reason for Referral
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:*

Consultation Only (Behavioral Health Assessment)Individual TherapyGroup TherapyFamily TherapyOther

Attach Documents (optional)
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*

Clear
Date*

MonthDayYear
Should be Empty: