Outpatient Referral New Client Registration Form * Required Information FieldsClient InformationClient Name* First Middle Last Are You A Previous Client?NoYesDOB*SSN*Race*American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhitePrefer Not To SayGender At Birth*MaleFemaleGender IdentityMaleFemalePreferred PronounStreet Address*City*Zip Code*Cell #*Home #Email AddressInsurance Name*Self Pay / Private PayAmbetterBCBS (Florida Blue)Florida Community CareMolina MarketplaceTri-Care EastUnited Behavioral HealthVA – Community Care NetworkAetna Better Health – Healthy KidsCarelon – Healthy KidsCarelonCMS – Title 19 – SunshineCMS – Title 21 – SunshineFlorida Community Care (BSN)HumanaMedicaidMolina Healthcare (Region 1 Marianna)Simply Health CareSunshine HealthUnited Health Care/ OptumFlorida Blue / Blue Cross Blue ShieldMedicare AdvantageBlue Medicare Classic Plus HMOMedicare Preferred HMOUnited MedicareMember ID #Primary Care Physician (PCP)PCP Phone #PCP Fax #Preferred LanguageName of School (if applicable)GradeWhere did you hear about us?No AnswerInsuranceInternet / Social MediaFriend / FamilyInternal Agency Provider ListChild Protective InvestigatorDependency Case ManagerProbation / Parole OfficerOtherAdditional InformationBriefly describe reason for the referral*Any current and/or recent risk factors (ex. Baker Acts, self-injurious, aggression, arrest, substance use) If so please briefly describeIs the client currently receiving any mental health services?*YesNoIf yes, where?Please describeParent/Caregiver Information (if not above client)(Note: If NOT biological parent, court guardianship paperwork MUST accompany Registration FormName First Middle Last Cell or Home Phone #EmailRelationship to ClientBio-ParentAdoptiveRelativeNon-RelativeFoster ParentOtherPlacement Type (if applicable)Parent / CaregiverGroup HomeShelterOtherPermission to send text message appointment reminder to client or guardian*YesNoGuardianship Document OneAccepted file types: pdf, png, gif, jpg.Guardianship Document TwoAccepted file types: pdf, png, gif, jpg.Referral Source (if applicable)Agency NameName First Middle Last Cell #Email Supervisor NameCell #Email Name of Community Based Care Organization (CBC), if applicableServices Requested (check all that are applicable)Services Mental Health Assessment Individual Counseling Family Counseling Therapeutic Visitation Target Case Management Adult Housing Program Substance Abuse (Lakeland Only) Psychiatry (THERAPY CLIENTS ONLY) Attestation* By checking this field, I attest I am the author of this documentCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
