School Referral Form
Thanks for referring your student 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: *
Your answer
Referring School Location: *
Required
Please note: If any of the following are true, we will unfortunately not be able to accept the referred student into our program, and it would be better to refer the patient elsewhere: *
Required
Student First Name: *
Your answer
Student Last Name: *
Your answer
Student Gender: *
Your answer
Preferred Pronouns (what's this? www.mypronouns.org):
Your answer
Student Date of Birth: *
MM
/
DD
/
YYYY
Current Grade (or last grade completed): *
Parent/Guardian Name: *
Parent/Guardian Phone: *
Your answer
Email Address (if known):
Your answer
Student Street Address: *
Your answer
Student City: *
Your answer
Student State: *
Student Zip Code: *
Your answer
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: *
Your answer
Insurance ID Number: *
Your answer
Relationship of Patient to Insurance Subscriber: *
NOTE - the subscriber is the person who purchased the insurance policy
Subscriber Name: *
Your answer
Insurance Subscriber Date of Birth: *
MM
/
DD
/
YYYY
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:
Your answer
Secondary Insurance ID Number:
Your answer
Relationship of Patient to Secondary Insurance Subscriber:
NOTE - the subscriber is the person who purchased the insurance policy
Secondary Insurance Subscriber Name:
Your answer
Secondary Insurance Subscriber Date of Birth:
MM
/
DD
/
YYYY
Reason for Appointment/Referral: *
Please be as specific as possible.
Your answer
Was permission obtained from the parent 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): *
Your answer
Phone Number (and Extension, if Required) Where You Can Be Reached, if Needed: *
Your answer
Fax Number or Email (if preferred) to Provide Feedback, Updates, or Ask Questions: *
Your answer
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