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*SSNRaceGender*MaleFemalePreferred LanguageInsurance Name*Aetna Better Health - BeaconBetter Health - BeaconHealthy Kids - Simply Health - BeaconHumana - BeaconMolina - BeaconSimply Health - BeaconLight House Health PlansMedicaidMagellan Complete CareStaywell - WellCareCMS - Staywell - Title 19CMS - Staywell - Title 21Healthy Kids - Staywell KidsCenpatico - SunshineHealthy Kids - SunshineUnited Health Care - MedicaidUnited Health Care - CommercialAmBetter - SunshineInsurance NumberStreet Address*City*Zip Code*Name Of SchoolGradeTeacherName of Primary Care PhysicianPhone NumberCaregiver Demographic Informationif not parents, guardianship paperwork must accompany this referralNamePhone NumberGuardianship 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) Mental Health Assessment Individual Counseling Therapeutic Visitation Family Counseling Targeted Case Management Substance Abuse (Polk, Hardee, Highlands) CAPTCHAEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
