Redeemed Wellness Center - Referral Form
Submission of this form is not a diagnosis, enrollment, or guarantee of services.One referral per individual.
REFERRAL TYPE
*
Self-Referral
Religious Organization
School
Medical Provider
Community Organization
REFERRING PARTY INFORMATION
Name of Person Completing This Form:
*
Referring Agency or Organization Name (if not Self-Referral):
Referring Representative Title/Role:
Referring Representative Email:
example@example.com
Referring Representative Phone Number:
PERSON BEING REFERRED
Full Legal Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Female
Male
Other
Prefer not to say
Primary Language:
*
English
Spanish
Other
PRIMARY CONTACT INFORMATION
Contact Person Name:
*
Back
Next
Relationship to Person Being Referred:
*
Self
Parent
Legal Guardian
Caregiver
Case Manager
Religious Leader/Mentor
Other
Contact Phone Number:
*
Contact Email Address:
*
example@example.com
REASON FOR REFERRAL
REASON FOR REFERRAL
*
Anxiety or stress
Depression or mood concerns
Behavioral concerns
Trauma or grief
Social or peer-related concerns
Family or parenting support
Youth or adolescent support
Case management needs
Peer support
Preventive or wellness support
Are there immediate safety concerns?
*
No
Yes
REQUESTED SERVICES
REQUESTED SERVICES
*
Behavioral Health Intake
Individual Therapy
Family Therapy
Youth Therapy
Parenting Support
Peer Support
Case Management
Not sure
Preferred Service Format:
*
In person
Telehealth
No preference
INSURANCE INFORMATION
Do you currently have insurance?
*
Yes
No
Insurance Type:
*
ProviderOne/Apple Health Medicaid
WellPoint Medicaid
Molina Healthcare Medicaid
Amerigroup Medicaid
UnitedHealthcare Community Plan
Coordinated Care Medicaid
Private Insurance
Private Pay
Other
Insurance Card Upload: JPG, PNG, or PDF
Browse Files
Drag and drop files here
Choose a file
Cancel
of
CONSENT AND ACKNOWLEDGMENT
*
I understand Redeemed Wellness Center will obtain all required consents directly.
I understand submission of this form does not guarantee services.
Back
Next
I understand information will not be shared without written authorization.
SIGNATURE
Name:
*
Electronic Signature:
*
Date:
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: