Registration/Referral Form

Registration/Referral Form

There are required areas in this form. Please fill out as much as possible and follow all directions below.
Referral Date

MonthDayYear
Date
Client Name*

First NameMiddle NameLast Name
Marital Status*
Maiden Name if Married
Program to be enrolled into*

Mental HealthSubstance Abuse
Referral Source (if applicable)

First NameLast Name
Referral Phone (if applicable)

Area CodePhone Number
Referral Email (if applicable)
example@example.com
Parent/Guardian Name for Clients under the age of 18

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence*
Home Phone (If home phone is cell, put that here. If unknown at time of referral put "UNK.")*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Is it ok to send you reminder text messages regarding appointments?*
Is it ok to send you information via email?*
Client Email (DMH requires an email unless the client refuses. If they refuse state "Refused." If you don't know the email, put "UNK" so we know to get it.)*
example@example.com
Date of Birth*
Age*
Race*
Social Security Number (if not know put "UNK". SSN will be needed before pre-auth can be sent to DMH.)*
Gender*

MaleFemaleOther
Living Situation (In own home, homeless, etc.)*
Guardian required (If so put information. If none put "NONE.")*
Preferred Language*
Military Status*
Type of Residence*
School (if applicable)
Grade (if applicable)
Female
Are you pregnant?
What is your due date?

MonthDayYear
Date
Do you have an OB/GYN? Who?
Drug Use

For IV and non-IV drug use.
Does the client currently use any non-prescribed drugs? *
Type of drugs
Has the client used drugs in the past?
Last date drugs were taken, if applicable:

MonthDayYear
Date
Tobacco Use

This includes all products that contain nicotine.
Does the client currently use any tobacco products or products that contain nicotine?*
What type?
How often per day?
Tobacco Helpline Information accepted / declined by client?
Caffeine Use
Does the client drink or eat anything that contains caffeine?*
What type?
How often per day?
Referral Reasoning
How did you hear about AWS? *
Reason for referral/Reason for seeking services: *
Insurance
Type of Insurance (If Medicaid, only the ID number is needed. If they do not know their number at time of referral put "UKN" in all boxes.)*

Insurance NameCustomer ID #Policy #Group #
Responsible Party other than self :

First NameLast Name
Date of Birth of Responsible Party

MonthDayYear
Date
Requested Therapist (if applicable)

First NameLast Name
Requested Case Manager (if applicable)

First NameLast Name
Staff Email if being submitted by staff (if applicable)
example@example.com
Attachments

If there are any attachments that need to be sent, please add them here
Attachments (If there is more than one file that needs to be attached, just click on the "Browse Files" button again you can add more.)

Browse Files

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Submit this referral to AWS Behavioral Health

Once you have finished this form, please click on the "Submit" button below.
Should be Empty:

Registration/Referral Form

Female

Drug Use

Tobacco Use

Caffeine Use

Referral Reasoning

Insurance

Attachments

Submit this referral to AWS Behavioral Health