One Me To Be Referral Form
Individual Information
Client's Name
*
First Name
Last Name
Client's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Individual Gender
*
Please Select
Male
Female
Non-binary
X (another gender marker)
Prefer not to say
Race
Please Select
Black
White
Hispanic
Asian
Native American
Middle Eastern
Pacific Islander
Multiracial
Other
Individual Primary Language
Please Select
English
Spanish
French
German
Italian
Portuguese
Chinese
Mandarin Chinese
Japanese
Korean
Arabic
Hindi
Urdu
Bengali
Russian
Vietnamese
Tagalog
Punjabi
Polish
Turkish
Other
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Medicaid Insurance
*
Please Select
N/A
Anthem Medicaid
AmeriHealth Medicaid
Aetna OhioRISE
Buckeye Medicaid
CareSource Medicaid
Molina
Ohio Medicaid
UnitedHealthcare
If you have Commercial coverage please choose in the section below( Please include subscriber's information including date of birth
Member ID#
Commercial Insurance (if applicable)
*
Please Select
No Commercial plans
Anthem BCBS
Medical Mutual
Member ID#
Group# (if applicable)
Parent/Guardian Name (Subscriber's name)
First Name
Last Name
Relationship
Subscriber's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Phone Number (if different from patient)
Please enter a valid phone number.
Format: (000) 000-0000.
Email (if different from patient)
example@example.com
Age group of patient being seen
Adult 18 - 40 years
Early Adolescent 11-13yr
Mid Adolescent 14-17 years
Children 8 - 10 years
Specify service Individual is considering
*
Individual Therapy (Mental Health)
Group Therapy (Mental Health ONLY)
Case Management with Individual Therapy
Substance Use services
Other
Select all applicable challenges below for the Individual referred (check all that apply)
*
Ability to avoid dangers/hazards
Anger
Anxiety
Community Linkage of Services
Daily living skills
Depression
Grief
Housing
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Maintaining personal affairs
Medication Education
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Sustainable employment
Trauma
Truancy
Whole Health/Wellness
Youth to Young Adult Transition
Other
Referral Source
Submit
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