Shining Minds LV- Referral for Services

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Client Information
*

Client's Name, Preferred Name and Pronouns:

Client Date of Birth *

Primary Insurance: *

Insurances Accepted:

Medicaid FFS (Fee For Service) "Straight Medicaid"

SilverSummit Medicaid

Anthem Blue Cross and Blue Shield Medicaid

Health Plan of Nevada, Sierra Health and Life or UMR

"Medicaid Expansion Program"

Molina Healthplan of Nevada

CareSource Mediciad

Aetna

Ambetter from SilverSummit Healthplan (Commerical)

Blue Cross Blue Shield Commercial

Behavioral Health Care Options

Cigna

Medicare (please call for Advantage Plans)

Tricare/TriWest

United HealthCare

Victims of Crime

Payments are also accepted in office via cash as well as through the client portal.

To determine if your insurance plan will cover services, please call your insurance company or contact us for more information. Co-payment is due at the time of service or receipt of invoice.

Required

Insurance Company and Number:

Secondary Insurance:

Client/Caregiver/Consenting Adult Contact Information *

Client/Caregiver/Consenting Adult Email Address *

(NECESSARY for portal access & Consents)

Where does the client live:

Birth Parent(s)

Foster Parent(s)

Legal Guardian

Self/Adult

Other:

Clear selection

Address:

Phone: *

Person consenting if client is minor *

NA - Client is over 18

Birth Parent

Foster Parent

Legal Guardian

State of Nevada (DFS Case)

Other

Caregiver Name:

If more than one, list all

Parent/Guardian #1:

Parent/Guardian #2:

Best phone number/email to contact client/guardian at: *

(email is NECESSARY for consents to be sent)

Foster Youth, HLOC or AFC:

Services being requested for this client/family: *

Family Therapy

Individual Therapy

Group Therapy

Couples Couseling

Mental Health Assessment w/ Recommendations

PSR/BST Only

Psycho-Sexual Assessment - additional fees WILL apply

.157 / .555 Assessment - an additional fee starting $99.00 WILL apply. Contact Michael

Accelerated Resolution Therapy (A.R.T) - additional fees may apply

Other:

Required

Other Current Mental Health Services: *

Yes

Unsure; please ask the client

IF Yes, please state Month and Facility/Agency

Required

Other Therapeutic services this year: *

Yes

Unsure; please ask the client

IF Yes, please state Month and Facility/Agency

Required

Has Client been hospitalized this year, When and Where: *

Service Setting: *

In-Office (7040 Laredo St Ste D, Las Vegas, NV 89117)

Tele-Health

Community

Required

Regarding Service Setting:

For in-home service please contact the office to discuss options.

Regarding Availability:

The Shining Minds administration team will try their best to match you with a clinician who can accommodate your scheduling preferences and chosen options regarding time and days. Please keep in mind that our clinicians may not have your first preferred time or day available but will try their best to accommodate. If you have a very particular schedule request it may cause a longer wait time to be assigned due to our clinicians' current availability.

Availability: Days *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Unsure; please ask the client

Required

Availability Times: *

Prefer early mornings 7a-10am

Prefer mornings 10a-12p

Prefer early afternoons 12p-3p

Prefer afternoons 3p-6p

Prefer early evenings 6p-9p

Prefer evenings 9p-11p

Open

Reason for Referral: *

Culturally-Sensitive, Religious and / or Competent Care:

Any Additional Information:

Any additional information that would be helpful pertaining to the client and their needed services?

Requested Clinician:

Any particular reason for requested clinician (ie friends therapist/Bio/Psytoday)?

How did you hear about the Agency:

Referral Source Information *

Name:
Phone Number:
Email Address:
Relationship:
Release of Information requested?:

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