Referral Form
Please complete the following form for Group therapy services available at Community Impact
Email address *
Client Name: *
Your answer
Address: *
Your answer
City: *
Your answer
State *
Your answer
Zip Code *
Your answer
Client's Date Of Birth: *
Your answer
Client's Age: *
Your answer
Client Sex: *
Relationship Status: *
Contact information
Please provide the following information for us to coordinate an intake appoitment
Home Phone Number
Your answer
Cell Phone Number *
Your answer
Email Address: *
Your answer
Emergency Contact: *
Your answer
Name of the person completing this referral:
Your answer
INSURANCE INFORMATION:
Insurance Type *
Your answer
Card Number/ Subscriber Number *
Your answer
Group Number
Your answer
Name of Insurance Subscriber: *
(Please also include their address if it is different then the client)
Your answer
Subscriber's Relationship to the Client: *
Your answer
Subscriber's Date of Birth: *
Your answer
Subscriber's Employer:
Your answer
Copayment:
This should be noted on the front of the card.
Your answer
Current Concerns and Additional Information
This information will help us provide the best fit regarding a provider for yourself or the referring client.
What are your or the client's current concerns and goals for group therapy: *
Your answer
Which Group Therapy Session are you interested in? *
Required
How were you referred to Community Impact?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms