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: *
Your answer
Last Name of Potential Patient: *
Your answer
Gender of Potential Patient: *
Your answer
Preferred Pronouns (what's this? www.mypronouns.org) of Potential Patient:
Your answer
Date of Birth of Potential Patient: *
Your answer
Current Grade (or last grade completed) of Potential Patient: *
Choose
N/A - THIS REFERRAL IS FOR A SCHOOL STAFF MEMBER
N/A - THIS REFERRAL IS FOR AN ADULT FAMILY MEMBER OF A STUDENT
Pre-K
K
1
2
3
4
5
6
7
8
Parent/Guardian Name of Potential Patient (put N/A if potential patient is 18 or older): *
Your answer
Phone (or Parent/Guardian Phone) of Potential Patient: *
Your answer
Email Address (if known) of Potential Patient:
Your answer
Street Address of Potential Patient: *
Your answer
City of Potential Patient: *
Your answer
State of Potential Patient: *
Zip Code of Potential Patient: *
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 Potential Patient to Insurance Subscriber: *
NOTE - the subscriber is the person who purchased the insurance policy
Subscriber Name: *
Your answer
Insurance Subscriber Date of Birth: *
Your answer
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 Potential Patient to Secondary Insurance Subscriber:
NOTE - the subscriber is the person who purchased the insurance policy
Clear selection
Secondary Insurance Subscriber Name:
Your answer
Secondary Insurance Subscriber Date of Birth:
Your answer
Reason for Appointment/Referral: *
Please be as specific as possible.
Your answer
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): *
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
Submit
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