Group Referral Form
Date *
MM
/
DD
/
YYYY
Client Email *
Client Name (First and Last Name) *
Preferred Name
Client Date of Birth *
MM
/
DD
/
YYYY
Client Address (Street, City, State)
State *
Zip Code
Client Phone Number *
Which Group is the client registering for
It is okay for us to leave a voice mail or to text you at this number? *
Is the client currently seeing one of our clinicians? *
If the client is a current client, which clinician are they working with. *
How did you find us? *
Name of person completing form if different from the client.
Relationship to Client
If this is a referral for someone, please provide a reason for referral.
Email of person completing form if different from the client.
Does the client have insurance? *
Insurance Carrier
If the client is a new client, please enter their insurance information below. If the client is a current client, skip this section.
Member ID Number (with Alpha Prefix if applicable) for the Insurance Company listed above.
Group Number
Policy Holder's Name if Different From Clients
Policy Holder's Date of Birth if Different From Clients
MM
/
DD
/
YYYY
Policy Holder's Address if Different From Client's
Do you have mental/behavioral health benefits?
Clear selection
If you have a deductible what is the amount of your deductible?
Has your deductible been met for this benefit year?
Clear selection
What is your copay?
Thank you for for submitting your appointment request a Registration Specialist will be in touch with you in the next two business days.
Submit
Never submit passwords through Google Forms.
This form was created inside of Telebehavioral Health.US. Report Abuse