Caladrius Therapy Referral Form

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For providers: please use this form to send a referral to Caladrius Therapy.

Referral Source (Agency/Person Name) *

Referral Source Email Address *

Referral Source Phone Number *

Referral Source Address

Referral Source Fax Number

Please indicate your preferred method for receiving confirmation on this referral.
*

Fax

Client Name *

Client Phone Number *

Client Email Address *

(If Minor) Client's Parent/Legal Guardian Name

(If Minor) Client's Parent/Legal Guardian Relationship

Client Date of Birth *

Client Sex Assigned at Birth

Client Gender Identity

Client Pronouns

Reason(s) For Referral (check all that apply) *

Individual Therapy

Couples Therapy

Family Therapy

Group Therapy

Parent Coaching

Play Therapy

Comprehensive Clinical Assessment

TF-CBT

DBT Group

DBT Individual

EMDR

Brainspotting

Sandtray Therapy

Reunification Therapy

Sex Therapy

Other:

Required

Brief Description of Reason For Referral

(PLEASE FORWARD MEDICAL & BEHAVIORAL INFORMATION, COURT REPORTS, SOCIAL SUMMARIES, PREVIOUS EVALUATIONS, ETC.)

Billing Information / Insurance Company (select all that apply) *

Self-Pay

AETNA

BCBS

Blue Value / Blue Home (out of network at this time)

Healthy Blue (Medicaid)

United HealthCare / Optum Commercial

United EAP

United Community (Medicaid)

Carolina Complete Health (Medicaid)

Amerihealth (Medicaid)

Alliance Medicaid

Partners Medicaid

Trillium Medicaid

Cigna (out of network as of February 2025)

Medicare (out of network with most plans- must disclose if recipient)

Request for Sliding Scale

Other:

Required

Submit

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