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New Mettle Works Referral Intake Form
Please complete this form in its entirety. A respective staff member from Mettle Works will be contacted once all documentation is received for continued intake and assessment. Please attach a copy of the Client's Photo ID and Insurance Card.
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* Indicates required question
Client Name:
*
Your answer
Gender:
*
Your answer
Address:
*
Your answer
Phone Number:
*
Your answer
Email:
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Medicaid Number:
*
Your answer
Active Date:
MM
/
DD
/
YYYY
Services Requested
*
Therapy
Psychiatric
PRP
Supported Employment
Anger Managment
Life Success Academy - PHP/SUD
Life Success Academy - PHP/MH
Mandated Mental Health Evaluation
Mandated SUD Evaluation
Required
Medicare Insurance Card #:
Your answer
Active Date:
MM
/
DD
/
YYYY
Are the requested services court mandated?
*
Yes: Yes - the services are court mandated
No: No - the services are not court mandated
Required
Will the services identified in the assessment be supported by the referring agent?
*
Yes
No
Required
BCBS Insurance Card #:
Your answer
Active Date:
MM
/
DD
/
YYYY
Policy Holder Name:
*
Your answer
Policy Holder Address:
*
Your answer
Previous Diagnosis:
Your answer
Current Mental Health Provider:
Your answer
Referral Source Name:
*
Your answer
Referral Source Agency or Organization:
*
Your answer
Referral Sources Email:
*
Your answer
Referral Sources Phone#:
*
Your answer
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