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

Please email us at info@noroozclinic.com if you have any questions.

Address: 1560 Brookhollow, Suite 214, Santa Ana, CA 92705
Phone Number: (714) 386-9171

Please email us or give us a call after you submit this form.
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Email *
Referring Agency Information
Please fill out your information.
Email Address *
Agency/Department *
Email *
Phone *
Date *
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DD
/
YYYY
Patient Information
Please fill in the patient's information in this section.
Name *
Gender *
Phone *
Email Address *
Date of Birth *
MM
/
DD
/
YYYY
Ethnicity
Language
Availabilities of Patient (please also check either morning or evening at the bottom of this list and select all that apply) *
Required
Parent/Caregiver Information
Name
Relationship
Address
Phone
Language
Where do you prefer your session to take place? *
Reasons for Referral/ Type of Services (Individual/Couples/Family therapy, psychological assessment, etc.) *
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 *
Please Sign Referring Person's Name & Date *
A copy of your responses will be emailed to the address you provided.
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