Referral Form

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Referral Form

Send Referrals to Blue Bell Behavioral Health- Casa Grande 520-375-2682. info@bluebellmgmt.com

Email *

Facility or Individual Contact Providing Referral (Name and Phone) *

Services Requested (Counseling, Case Management, Job Skills/ Job Attainment, Other) *

Name *

Phone number *

Date of Birth *

YYYY

Address *

Insurance Carrier Or Self Pay *

Primary Care Physician Name and Contact *

Recent or Prior Counseling Information *

I have no prior experience at any counseling or therapeutic services.

I have more than one year experience at any counseling or therapeutic services.

I have recently in last 90 days be in inpatient or other higher level of care.

I am currently receiving services at another counseling or therapeutic service.

Other:

Required

Occupation/ Retirement or Unemployment Status *

To be considered for low income scholarship or free clinic services, sliding scale you must state your income. If you are not please select declined. *

Declined to apply for scholarship, free clinic, or sliding scale.

I am a disabled veteran.

I am homeless.

I am an an active duty service member or family member of active duty service member.

My gross income is or less than $15,060 as a single adult.

My gross income is or less than $26,496 and I have one dependent.

My gross income is or less than $25,820 and I have two dependents.

My gross income is or less than $31,200 and I have three dependents.

My gross income is or less than $36,580 and I have four dependents.

My gross income is or less than $$52,720 and I have five or more dependents.

Required

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