MENTAL HEALTH REFERRAL FORM

REFERRAL SOURCE
AGENCY	PHONE
LOCATION	EMAIL
FORM COMPLETED BY	PHONE	DATE

RECEIVING AGENCY
AGENCY	PHONE
LOCATION	EMAIL

CLIENT INFORMATION
LAST NAME	FIRST NAME AND MI
DATE OF BIRTH	GENDER
SOCIAL SECURITY #	MEDICAID #
INTERPRETER REQUIRED?	LANGUAGE REQUIRED
GUARDIAN NAME	GUARDIAN RELATIONSHIP
CLIENT’S ADDRESS	CELL PHONE
HOME PHONE
WORK PHONE
EMAIL

PRESENTING CONCERNS / COMMENTS Attach additional sheets and / or supporting documentation as deemed necessary.
REASON FOR REFERRAL
PATIENT AWARE OF REASON FOR REFERRAL? IF NOT, PLEASE EXPLAIN.
SERVICE / SPECIALTY REQUESTED
ADDITIONAL COMMENTS

INSURANCE INFORMATION
AUTHORIZATION REQUIRED?	YES	NO	AUTH #	# OF VISITS	AUTH EXP. DATE
PPO	HMO	OTHER	INSURANCE PLAN
INSURANCE ID	MEDICAL GROUP	PHONE #
INSURANCE HOLDER’S NAME	RELATIONSHIP TO PATIENT	DOB

RECEIVING AGENCY | DOCUMENTATION OF RECEIPT
METHOD OF DELIVERY	DATE RECEIVED

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