Vida Clinic Referral Form
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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 and School District, Hospital, Community Based Organizations, etc... *
Referral Source Phone Number *
Consent to Refer for Services *
Required
Referred Client Name *
Referred Client Date of Birth *
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 (BCBS, Aetna, Cigna, Medicaid, etc...)
Referred Client Insurance ID Number
Preferred Method of Contact for Client or for Guardian if client is under 18 years of age.  
*** 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 *
Language of Family
If there is a mental health crisis or there is concern of harm to self or others, please call 911.   What difficulties are impacting the referred client/family the most right now and/or additional information for the Vida Clinic Therapist. *
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.)
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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