Strategic Therapy Associates - Referral Form for Referring Workers
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Email *
Service Region: *
Referring Worker Name: *
Referring Worker Agency *
Referring Worker Phone Number: *
Referring Worker Fax Number: (*Required for Monthly Reports) *
Referring Worker Email: *
Referring Worker Physical Office Address
Client's Full Name: *
Client's Date of Birth: *
Client's Social Security Number:
Client's Gender: *
Client's Race: *
Parent/Guardian Name, if under 18:
Parent/Guardian Relationship to Client, if under 18:
Foster Parent Name & Number, if applicable:
Parent/Guardian or Adult Client Email: (*Required for Patient Portal) *
Full Home Address: (City, State & Zip Code) *
Cell Phone #: *
Home Phone #: *
Services Requested: *
Reason for Referral: (List specific behaviors and previous interventions) *
Funding:  *
Medicaid Policy Number: (12 digits) *
Medicaid MCO:  *
Commercial Insurance: (*Must list if in addition to Medicaid)
Commercial Insurance Number:
Commercial Subscriber Name: 
Commercial Subscriber Date of Birth:
CSA/AMI/EBA or other contract information
Purchase Order Number or Contract Number: 
Contract Approval Dates:
Number of Units Approved: (*Add per week or month)
Contract Contact Person: (Name, phone, email)
A copy of your responses will be emailed to the address you provided.
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