Referral Form
1: WHO IS REQUESTING SERVICES?
I am the client requesting services for myself
I am the parent/legal guardian representing services for my child
I am referring another adult
I am a professional referring a client
2: CLIENT INFORMATION
Client Full Name:
*
Date
/
Month
/
Day
Year
Date
Gender:
*
Race/Ethnicity:
*
Primary Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City/State/Zip:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County:
*
Primary Phone:
*
Format: (000) 000-0000.
Email:
*
Preferred Method of Contact:
*
Phone
Text
Email
3: IF CLIENT IS A MINOR
Parent/Guardian Name:
First Name
Last Name
Relationship to Client:
Phone:
Format: (000) 000-0000.
Email:
Legal Custody?
Yes
No
4: REFERRAL SOURCE INFORMATION
(Required if not self-referral)
Referring Person Name:
First Name
Last Name
Agency/Organization:
Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
example@example.com
Referral Relationship to Client:
Has the client agreed to this referral?
Yes
No
5: INSURANCE INFORMATION
Insurance Type:
Trillium
Healthy Blue
WellCare
AmeriHealth Crisis
Carolina Complete
Medicaid Direct
Commercial Insurance
Uninsured
Insurance ID Number (Medicaid = 9 digits + 1 letter)
Upload Insurance Card (Front & Back) :
Browse Files
Drag and drop files here
Choose a file
Cancel
of
6: SERVICES REQUESTED
*
Outpatient Threapy (OPT)
Intensive In-Home (IIH)
Peer Support (Adult)
Community Support / Skill Building
Individual Therapy
Group Therapy
Combination of Services
Not Sure - Requesting Clinical Assessment
7: PRESENTING CONCERNS
*
Depression
Anxiety
Behavioral Issues
Autism Spectrum Concerns
ADHD
Trauma
Substance Use
Family Conflict
School Problems
Emotional Regulation
Crisis Risk
Difficulty with Daily Living Skills
Other
Brief Description of Current Concerns:
8: URGENCY
Is the client currently in crisis?
*
Yes
No
If yes, explain:
9: AUTHORIZATION FOR RELEASE OF INFORMATION (ROI)
I authorize START Wellness Inc. to:
*
Obtain information from referring providers
Release information to referring providers
Exchange information (two-way communication)
With:
Name/Agency:
*
Phone:
*
Format: (000) 000-0000.
Email:
*
Purpose of Disclosure
*
Coordination of Care
Assessment
Insurance Authorization
Other
Expiration of Authorization:
*
1 year from signature
Upon Discharge
Specific Date:
I understand that I may revoke this authorization in writing at any time
Signature:
*
Date:
*
/
Month
/
Day
Year
Date
10: REFERRAL CONSENT
I certify that the information provided is accurate to the best of my knowledge:
*
Date:
*
/
Month
/
Day
Year
Date
Continue
Continue
Should be Empty: