Referral for Group Therapy
You will be contacted within 2 business days of receipt of form to confirm that we are able to take your client.  Clients are first matched with an individual provider to assess fit for the group(s) of interest. Progress assessments occur once every 90 day period of participation in group. Your individual provider will contact you the client through their preferred communication method to set up the intake assessment. Your client will receive a welcome email from Therapy Notes and can complete intake paperwork through the portal. We look forward to working with you!  **If this is a CCS referral please authorize 1.25 or 1.75 Individual Family Psychoeducation weekly**
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Agency Referring
Name of Person Referring
Referral Source Email
Service Facilitator/Referral Source Phone
How would your client prefer to be contacted?
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Funding Source 
**If client is CCS and also has Medicaid/Badgercare, please mark CCS for funding source**

*If your insurance is not listed, we are not in network with them. We advise calling the number on the back of your insurance card to find services that are in network or finding out about your out of network benefits.
*We do not currently contract with Anthem BCBS Commercial or Anthem BCBS Badgercare
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Client Name:
Preferred Name
Pronouns
Date of Birth
MM
/
DD
/
YYYY
Address (Street, City, State and Zip code)
Phone Number
Is it OK for us to leave text/voicemails at this number?
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Email
What group(s) are you looking to join? Select all
Is there anything else we should know about this client?
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