Referral Submission Form

Maricopa County Juror Counseling Referral

This form is for jurors referred through the Maricopa County Jury Office for counseling services related to jury duty.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Court Referral Information
Referring Jury Office / Court Department
Referring Court Staff Name

First NameLast Name
Referring Court Staff Email
example@example.com
Referring Court Staff Phone
Please enter a valid phone number.Format: (000) 000-0000.
Juror Information
Juror Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Juror Claim Number
Referral Notes / Additional Information

Arizona Department of Public Safety (DPS) Referral

This section is for referrals submitted by Arizona Department of Public Safety personnel requesting psychological or counseling services for DPS employees.
DPS Referring Contact
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DPS Referring Staff Name

First NameLast Name
DPS Referring Staff Email
example@example.com
DPS Referring Staff Phone
Please enter a valid phone number.Format: (000) 000-0000.
DPS Employee Being Referred
Employee Name

First NameLast Name
Employee Rank / Position
Employee Phone
Please enter a valid phone number.Format: (000) 000-0000.
Employee Email
example@example.com
Type of Service Requested

Other
Urgency of Request
Referral Notes / Additional Information
Supporting Documentation (Optional)

Cancelof

Referring Agency Information
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referring Agency or Organization
Referring Contact Name

First NameLast Name
Role / Title
Referring Contact Email
example@example.com
Referring Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?
Client Information
Primary Reason for Referral
Urgency Level
Client Name

First NameLast Name
Client DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last 4 of SSN
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client Email Address
example@example.com
Insurance Information
Insurance Type
AHCCCS Member ID (Access ID)
AHCCCS Health Plan
If known, select the member's AHCCCS health plan.

Submit Referral
Please click Submit Referral to securely send this information to our team.

Our intake team will review the referral and follow up as appropriate.

Thank you for trusting Guided Path Services with this referral. We are proud to serve the State of Arizona and look forward to helping guide individuals and families toward healing and hope.
Referral Source Tracking
Should be Empty:

Referral Type