Caladrius Therapy Referral Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

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

Email *

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

Play Therapy

Parent Coaching

Comprehensive Clinical Assessment

Trauma Informed Comprehensive Clinical Assessment

TF-CBT

EMDR

Brainspotting

Sex Therapy

Group Therapy

Reunification Therapy

Sandtray Therapy

Other:

Required

Brief Description of Reason For Referral

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

Billing Information / Primary Insurance Company *

Self-Pay

AETNA

BCBS

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

Healthy Blue

United HealthCare / Optum

United EAP

United Community

Partners Medicaid

Trillium

Alliance Medicaid (requires a single case agreement request/pre-authorization- call for more information)

Cigna (out of network as of February 2025)

Request for Sliding Scale

Other:

Does client have any other form of insurance? *

Yes

Unknown

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Caladrius.

Does this form look suspicious? Report

Forms