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WC Ops Referral Form
Please reach out to 1-866-886-HELP (4357) if you have any questions.
Name of person making referral.
*
First Name
Last Name
Relationship to client and phone number
*
What city this a referral for?
*
Houston
Dallas
Tyler
Midland/Odessa
Beaumont
Austin
San Antonio
Other
Clients Full Name
*
First Name
Last Name
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Client's Race
*
Please Select
Black
White
African American
Asian
American Indian
Alaska Native
Native Hawaiian
Other Pacific Islander
Client's Sex (as assigned at birth)
*
Please Select
Male
Female
Intersex
Prefer not to say
Client's Insurance Carrier and Policy Number
*
Please upload a copy of the Client's Insurance Card (both front and back)
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Parent/Legal Guardian Name
*
First Name
Last Name
Parent/Legal Guardian Phone Number
*
example@example.com
Parent/Legal Guardian Email Address
*
example@example.com
Agency/Institution (if applicable)
What services are needed?
*
Skills Training / Development / Psychosocial Rehabilitative Services
Crisis Intervention
Therapy
Medication Management and Support
Psychiatric Services
unknown (please have someone give me a call to discuss)
Nature of referral:
*
Emergency (less than 24hrs)
Urgent (24hrs)
Routine (7 days)
Other
History of violence?
*
Yes
No
Unknown
History of suicide attempts
*
Yes
No
Unknown
History of psychiatric hosptialization(s)
*
Yes
No
Unknown
Briefly explain the client's current problem or need and describe any pertinent past information we should know.
*
Submit
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