Self-Referral Form
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Name *
Date of Birth *
MM
/
DD
/
YYYY
If applicable, name of guardian
Address *
Contact Number *
Email *
Insurance Carrier *
Required
Insurance Carrier Name (type N/A if self-pay) *
Insurance Member ID (type N/A if self-pay) *
Schedule Availability *
Morning
Afternoon
Any Time
Not Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
If school age, indicate which school
Preferred meeting format *
Brief description of why you are seeking services *
If you have medicaid you can receive case management* while you wait to begin therapy. Would you like for our case manager to call you and see if that is a service you may want?
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*Case management can help with basic needs like housing, utilities, or food access. They also can help with things like budgeting, medication access, finding community resources, goal setting, or parenting. For children, case managers can help advocate within the schools, find local activities for social interaction, and build support systems.
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