Norooz Clinic Foundation Referral Form
Direct Sliding Scale Mental Health Services Referral Form

Please email Nina at nhuynh@noroozclinic.com if you have any questions.

Address: 202 Fashion Lane, Suite 219, Tustin, CA 92780
Phone Number: 949.242.9720

Please email us or give us a call after you submit this form.

Referring Person/Title *
Your answer
Agency/Department *
Your answer
Email *
Your answer
Phone *
Your answer
Date *
Your answer
Patient Information:
Name *
Your answer
Address *
Your answer
Gender *
Phone *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Ethnicity
Your answer
Language
Your answer
Availabilities of Patient (please also check either morning or evening at the bottom of this list) *
Required
Parent/Caregiver Information:
Name
Your answer
Relationship
Your answer
Address
Your answer
Phone
Your answer
Language
Your answer
Reasons for Referral *
Your answer
Service Agreement & Authorization to Release Information
The referring party has explained to me the purpose for this referral and I agree to have a copy of this referral emailed or to take a copy of the referral to Norooz Clinic Foundation. I agree to attend any scheduled appointments with the Services.
I authorize the release of information between (referring agency) and Norooz Clinic Foundation for the period this service agreement remains in effect. This information will pertain to the reasons for referral and will be used for assessment and intake of the participant(s) to be served. This referral was explained to me in my primary language.
Please Sign Participant's Name & Date *
Your answer
Please Sign Referring Person's Name & Date *
Your answer
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