Vida Clinic Referral Form
For questions when submitting a referral, please email vidacare@vidaclinic.org
Sign in to Google to save your progress. Learn more
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: *
Required
Referred Client Name:
*
Referred Client Date of Birth:
(MM/DD/YYYY)
*
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:
(XXX) XXX-XXXX
*
Phone number to receive text:
(XXX) XXX-XXXX
*
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?
Clear selection
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: *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Vida Clinic. Report Abuse