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.
* Required
Name and Title of Referring School Official:
*
Your answer
Referring School Location:
*
Imagine Groveport Community School - Elementary (K to 4th)
Imagine Groveport Community School - Prep (5th to 8th)
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:
*
Student's treatment is court-ordered, as we don't do court-ordered treatment.
Student has any legal problems, court disputes, charges, or lawsuits that may require our staff to get involved, as we do not render opinions for court or provide letters for attorneys.
Student is involved in a custody dispute and parents want us to get involved, as we won't render opinions regarding custody arrangements.
NONE OF THESE ARE TRUE - not court-ordered, no legal problems or court disputes, and no custody disputes
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):
*
Choose
Pre-K
K
1
2
3
4
5
6
7
8
Parent/Guardian Name:
*
N/A - patient is 18-years-old or older
Other:
Parent/Guardian Phone:
*
Your answer
Email Address (if known):
Your answer
Student Street Address:
*
Your answer
Student City:
*
Your answer
Student State:
*
Ohio
Other:
Student Zip Code:
*
Your answer
Service(s) Requested:
*
You may choose as many as is needed.
Family Therapy/Counseling
Individual Therapy/Counseling
Psychiatric Medication Management (NOTE - all new patients are scheduled for an intake appointment for diagnostic purposes before being referred for medication management)
Psychological Testing - to clarify a diagnosis, confirm ADHD, test for Autism, rule out a learning disability, etc.)
Required
Scheduling Preference:
*
How soon would you like your patient to be seen? (Choose one.)
ASAP - they need the earliest available appointment.
Within 1 or 2 weeks, if possible.
More than 2 weeks, as they don't need the help immediately.
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.
Self-Pay (the patient has no insurance, chooses not to use it, or has an insurance not accepted at PFHL.)
Aetna/Meritain
Anthem/Blue Cross Blue Shield
Buckeye Health Plan (Medicaid)
CareSource
Cigna
HealthSmart Benefit Solutions
Humana
Magellan (out-of-network benefits only)
Medical Mutual (unfortunately, we aren't allowed to accept the HMO or narrow network plans)
Molina (Medicaid)
Ohio PPO Connect
Optima/OhioHealthy
OSU/NGS
Paramount Healthcare (Medicaid)
Student Resources (UHC) - OSU Student Health Insurance
UHC Community Plan (Medicaid)
United Healthcare (Optum, UHC, UMR, Golden Rule, Medica, etc)
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
Self
Child
Spouse
Other:
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.
None
Aetna/Meritain
Anthem/Blue Cross Blue Shield
Buckeye Health Plan (Medicaid)
CareSource
Cigna
HealthSmart Benefit Solutions
Humana
Medical Mutual (unfortunately, we aren't allowed to accept the HMO or narrow network plans)
Molina (Medicaid)
Ohio PPO Connect
Optima/OhioHealthy
OSU/NGS
Paramount Healthcare (Medicaid)
Student Resources (UHC) - OSU Student Health Insurance
UHC Community Plan (Medicaid)
United Healthcare (Optum, UHC, UMR, Golden Rule, Medica, etc)
Other:
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
Self
Child
Spouse
Other:
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.
*
Yes
No
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
Page 1 of 1
Never submit passwords through Google Forms.
This form was created inside of Providers for Healthy Living, LLC.
Report Abuse
Forms
