Outpatient Referral Referral For Outpatient Services **For ALL clients not in the care and custody of their parents, Court paperwork showing guardianship must accompany this referral.**Referral Source/Name*Agency Name*Name*Phone*Email* SupervisorPhoneEmail Community Based Care Organization (CBC) if applicablePermission to send text message appointment reminders to the referral source: Yes No Demographic InformationClient Name*DOB*SSN*RaceGender*MaleFemalePreferred LanguageInsurance Name*Lighthouse - Access Behavioral HealthHumana (Panhandle only) - Access Behavioral HealthAetna Better Health - BeaconBetter Health - BeaconHealthy Kids – Aetna Better Health – Coventry - BeaconHealthy Kids - Simply Health - BeaconHumana - BeaconMolina - BeaconSimply Health - BeaconMagellan Complete CareMedicaidSunshine Health (Medicaid)United Healthcare/Optum – Medicaid & CommercialStaywell - WellCareCMS - Staywell - Title 19 - WellcareCMS - Staywell - Title 21 - WellcareInsurance NumberStreet Address*City*Zip Code*Name Of SchoolGradeTeacherName of Primary Care PhysicianPhone NumberClient or Caregiver InformationNOTE: If you are not the client or parent of the above, guardianship paperwork MUST accompany this referral.NamePhone NumberEmail AddressGuardianship Document OneAccepted file types: pdf, png, gif, jpg.Guardianship Document TwoAccepted file types: pdf, png, gif, jpg.Placement Type Biological Relative Adoptive Non-Relative Foster Home Group Home Briefly describe the reason for referralCurrent and/or recent risk factors (ex: Baker Act, self-injurious, aggression, arrest, substance use)Is the client currently receiving any mental health services?*YesNoIf Yes, where?Please DescribeServices Requested Psychiatric (must receive counseling) (Tampa, Lakeland, and Orlando only) Mental Health Assessment Individual Counseling Therapeutic Visitation Family Counseling Targeted Case Management Substance Abuse (Polk, Hardee, Highlands) CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
