Outpatient Referral New Client Registration Form * Required Information FieldsClient InformationClient Name*DOB*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*Aetna Better Health – Coventry- BeaconAmbetterCMS – Title 19 – SunshineCMS – Title 21 – SunshineHealth Kids – Aetna Better Health – Coventry - BeaconHealthy Kids – Simply Health - BeaconHumana - Access Behavioral Health (Panhandle only)Humana - BeaconLighthouse – Access Behavioral HealthMagellan Complete CareMedicaidMolina HealthcareSimply Health Care - BeaconSunshine Health/CenpaticoUnited Health Care / Optum – MedicaidUnited Health Care / Optum - CommercialUnited Health Care/ Optum - VATri-Care EastMember 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 FormNameCell or Home Phone #EmailRelationship to Client Bio-Parent Adoptive Relative Non-Relative Foster Parent Other Placement 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 NameNameCell #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 Substance Abuse (Lakeland Only) Psychiatry (THERAPY CLIENTS ONLY) Attestation* By checking this field, I attest I am the author of this documentCAPTCHAEmailThis field is for validation purposes and should be left unchanged.
