ATR Integrated — Client Referral Form

ATR Integrated — Client Referral Form

Provide referral details and client information so our intake team can follow up within 24 hours.
Referral Source
Date of Referral

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referring Party Full Name

First NameMiddle NameLast Name
Agency / Organization
Title or Role
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Relationship to Client
Best Way to Reach You
Client Information
Client full name

First NameMiddle NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex / gender
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Current mailing address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred contact method
Safe to leave a voicemail?
Preferred language
Interpreter needed?
Current housing status
Anticipated release date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Emergency contact full name

First NameMiddle NameLast Name
Emergency contact phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance & Eligibility
AHCCCS ID / member number
AHCCCS health plan
Other insurance, if any
SMI determination
Currently enrolled with another behavioral health provider?
Reason for Referral
Primary Reason for Referral
Presenting Concerns

Other
Known Diagnoses
Current Substances Used and Frequency
Date of Last Use

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Medications
Prior Behavioral Health or Substance Use Treatment History
Risk & Safety
Current suicidal ideation?
Current homicidal ideation?
Recent hospitalization or detox in the last 30 days?
Details (if yes)
Any known safety concerns for staff or transport?
Legal / Justice Involvement
Is the client justice-involved?
Type of supervision
Probation/Parole officer or case manager name and contact
Court dates or reporting deadlines to be aware of
Services Requested
Services requested
Urgency
Preferred start date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Days/times client is available
Needs transportation to appointments?
Documents & Consent
Supporting Documents

Cancelof
Consent Acknowledgment
Referral Decision Acknowledgment
Referring Party Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional Notes
Should be Empty:

ATR Integrated — Client Referral Form

Referral Source

Client Information

Insurance & Eligibility

Reason for Referral

Risk & Safety

Legal / Justice Involvement

Services Requested

Documents & Consent