Vida Clinic Referral Form
For questions when submitting a referral, please email
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Email *
Referral Source Name:  
*Please specify name of person completing form*
Referral Source Title / Position: *
For example:  Teacher, Counselor, Nurse, Psychiatrist, Therapist, Case Manager,  etc...
Referral Source:  
*Please specify name of Agency, Campus, School District, Hospital, Community Based Organizations, etc.*
For Goodside referrals, please be sure to specify school district
Referral Source Phone Number: *
Consent to Refer for Services: *
Referred Client Name:
Referred Client Date of Birth:
Referral Priority
(Please indicate priority level for this referral and a scale of 1-3)

1 - Low priority (it is OK if the client is not contacted right away)

2 - Moderate priority (client could benefit from quick contact and intake within same week)

3 - High priority (client is not in danger to themselves and others, but needs urgent help and recommend to be contacted same day).
Parent/Guardian Name 
*If referred client is 18 years of age or younger*
Referred Client Street Address:
Referred Client City and State:
Referred Client Zip Code:
How would referred client like to be contacted?  
*Please ensure corresponding contact information is provided below*
Referred Client Insurance Name: *If applicable*
(Aetna, Sendero, Ambetter, etc.)
Referred Client Insurance ID Number: *If applicable*
Preferred Method of Contact for Client or Guardian:
*** Please provide all contact methods available to client.  Enter 00 if not available. ***
Phone number to receive call:
Phone number to receive text:
Email address of the Referred Client: *
Language of Client
What language does the client speak?
Language of Parent/Guardian:
What language does the parent speak?
What difficulties are impacting the referred client/family the most right now?
If there is a mental health crisis or there is concern of harm to self or others, please call 911. 
Additional information that may be helpful to Vida Clinic Therapists:
(hospital discharge date if applicable, grade level in school, specific contact requests, specific therapist request, etc.)
What language does the client prefer their therapist to speak?
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My organization will pay for this client's services up to 100% of what the client may owe for as long as services are needed: *
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