Referral Form

Client Referral Form
REFERRAL FORM is needed PRIOR to scheduling.

Please include if available:

• Copy of Insurance Card(s)
• Client’s completed CCA

Consent and Release can be signed in office if legal guardian is present at appointment, or you can sign at the end of this form electronically if you have authority to do so.

Fill out the requested information below, and click "submit" to submit the form. You will be prompted to e-sign and be given the opportunity to download the form as a PDF. You must carefully read the e-sign document to ensure all information is correct and any additional information is understood. It will be emailed to you as well.

If you prefer to print out and mail/email/fax in your paperwork, you may find the form below:
Client Information
Name

First NameLast Name
Date Of Birth

MonthDayYear
Date Of Birth
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Can we text you?

YesNo
Can we leave you a voicemail?

YesNo
Gender

MaleFemale
Parent / Legal Guardian (If Applicable)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Referral Agent
Agent Name
Referral Agency
Email
example@example.com
Relationship to Client
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Send Completed Report By:

FaxMailEmail
DSS Involvement
Is DSS Involved

YesNo
If DSS involved, please provide social worker's information
Insurance Information

Check All That Apply
BOTH MEDICAID AND OTHER INSURANCE MUST BE LISTED. We do not accept Medicare. Please call the office to check on other insurance.
MEDICAID

Vaya HealthPartners Behavioral HealthTrillium Health ResourcesAlliance HealthCarolina Complete Health Network (CCHN)UnitedHealth Community PlanAmeriHealthOther
If Other Medicaid, Please List
MEDICARE (Note: We do not accept Medicare Advantage Plans)

Medicare
COMMERCIAL PLAN

Blue Cross Blue Shield (BCBS)AetnaCignaOther
If Other Commercial Plan, Please List
INSURANCE ID NUMBER
Copy of Insurance Card(s)

Please submit any copies of your insurance information that you have available (front and back). This information is kept secure in accordance with federal HIPAA regulations.
File Upload:

Cancelof
Client's Current Diagnosis
Prescribing Doctor
Current Medication(s)
Prescribing Doctor's Office Number
Is This Assessment Court Ordered?

YesNo
Medical Necessity

In order for insurances to reimburse providers for Psychological Testing, the testing must be Medically Necessary. Medical Necessity is defined as; a service which in the opinion of the primary service provider is reasonably needed to prevent the worsening of a condition, to establish a diagnosis and/or to assist the covered individual to achieve maximum functional capacity. PLEASE CLEARLY DEFINE THE MEDICALLY NECESSARY REASONS FOR THIS INDIVIDUAL TO RECEIVE TESTING. Additionally, list current concerns and goals for this assessment. Please be as thorough as possible.
Information below must be provided to determine eligibility for testing prior to scheduling:
Testing Type
• Behavioral-Emotional/Developmental/Cognitive: Psychological assessment to assist with diagnostic clarification, assess current level of functioning and make recommendations for services and/or treatment if appropriate

• Eligibility Determination: Determination of eligibility for placement based on testing outcome.

• IDD Services: Required testing for IDD services

• Educational Testing: Please note insurances do not pay for academic testing.
Please check all that apply

Behavioral-Emotional/Developmental/CognitiveEligibility DeterminationIDD ServicesEducational TestingOther
Current Services (Please check all that apply)

Therapy/counselingRespite CareFoster placementCourt SystemPsychiatric careDSSResidential PlacementSpecial EducationMedical careCase Responsible Provider(s)Inpatient mental healthSpecialized TherapiesOther/None
Provider(s)
History: Please check all that apply (*Copies of prior assessments are helpful if available)

*Prior AssessmentMental Health ServicesMedical ServicesDevelopmental DisabilityMedicationEarly InterventionSpecial EducationDomestic ViolenceSubstance AbuseSuicidal HistoryAbuse/NeglectCriminal RecordOther/None
Name of Person signing this form

First NameLast Name
Signature

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Client Referral Form

Client Information

Parent / Legal Guardian (If Applicable)

Referral Agent

DSS Involvement

Insurance Information

Testing Type