Best Point Adult Online Referral Form

Adult Services Referral Form
If you happen to need assistance with this form, please contact Best Point's Centralized Intake Department at (513) 272-2800.
Date of Referral

MonthDayYear
Date
Person Making Referral

First NameLast Name
Referrer's Phone Number
Format: (000) 000-0000.
Referrer's Email Address
Referring Entity
Name of clinic, hospital, agency, etc.; enter “Self” if you are making a referral for yourself

Client Information
Client's Legal Name

First NameLast Name
Client's Legal Guardian (if applicable)

First NameLast Name
Client's Date of Birth

MonthDayYear
Client's Social Security Number
Client's Age
Client's Address

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number
Format: (000) 000-0000.
Primary Email Address
Gender at birth
Gender Identity
Race
Ethnicity
Interpretation Services Needed:
Preferred Language:

Insurance Information
What type of insurance does the client have?
Select Medicaid Plan
Medicaid Number (MMIS)
12 digits
Private or Medicare Insurance Provider
Policy Number
Group Number
Name of Policy Holder

First NameLast Name
Policy Holder's Date of Birth

MonthDayYear
Policy Holder's Relationship to Client

Safety Concerns

If the client is currently experiencing a mental health crisis please take them to the nearest hospital or reach out to 988 for immediate assistance. Hamilton County Crisis line: 513-584-8577 Butler County Crisis line: 1-844-427-4747 Warren/Clinton County Crisis line: 1-877-695-6333
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