School Referral Form
Thank you for referring to us for mental health care. We need some basic demographic, insurance, and clinical information in order to process the referral. All information submitted here is confidential and HIPAA-compliant.
Name and Title of Referring School Official: *
Referring School Location: *
Required
Please note: If any of the following are true, we will unfortunately not be able to accept the referred person into our program, and it would be better to refer the patient elsewhere: *
Required
First Name of Potential Patient: *
Last Name of Potential Patient: *
Gender of Potential Patient: *
Preferred Pronouns (what's this? www.mypronouns.org) of Potential Patient:
Date of Birth of Potential Patient: *
Current Grade (or last grade completed) of Potential Patient: *
Parent/Guardian Name of Potential Patient (put N/A if potential patient is 18 or older): *
Phone (or Parent/Guardian Phone) of Potential Patient: *
Email Address (if known) of Potential Patient:
Street Address of Potential Patient: *
City of Potential Patient: *
State of Potential Patient: *
Zip Code of Potential Patient: *
Service(s) Requested: *
You may choose as many as is needed.
Required
Scheduling Preference: *
How soon would you like your patient to be seen? (Choose one.)
Primary Insurance Company *
Select the patient's insurance company from the list below. If not found here, we likely do not accept the patient's insurance. You can call our office to ask at 614-664-3595. We do NOT accept any form of Medicare.
Insurance Phone Number for Mental Health Authorization/Questions: *
Insurance ID Number: *
Relationship of Potential Patient to Insurance Subscriber: *
NOTE - the subscriber is the person who purchased the insurance policy
Subscriber Name: *
Insurance Subscriber Date of Birth: *
Secondary Insurance Company *
Select the patient's insurance company from the list below. If not found here, we likely do not accept the patient's insurance. You can call our office to ask at 614-664-3595. We do NOT accept any form of Medicare.
Secondary Insurance Phone Number for Mental Health Authorization/Questions:
Secondary Insurance ID Number:
Relationship of Potential Patient to Secondary Insurance Subscriber:
NOTE - the subscriber is the person who purchased the insurance policy
Clear selection
Secondary Insurance Subscriber Name:
Secondary Insurance Subscriber Date of Birth:
Reason for Appointment/Referral: *
Please be as specific as possible.
Was permission obtained from the parent (if potential patient is under 18) or patient (if potential patient is 18 or older) for this referral and will they be expecting a call to schedule/discuss next steps? A signed release of information is a best practice in these situations. *
Name of Person Completing This Form (in Case of Questions): *
Phone Number (and Extension, if Required) Where You Can Be Reached, if Needed: *
Fax Number or Email (if preferred) to Provide Feedback, Updates, or Ask Questions: *
Submit
Never submit passwords through Google Forms.
This form was created inside of Providers for Healthy Living, LLC. Report Abuse