Self Referral Form

Request for Services

If you or a loved one need services (therapy, SUD and/or community counseling support), please complete this form and someone will contact you.

"*" indicates required fields

If the required field is unknown, please enter 'N/A' or 'Not Applicable'.

Name of person completing referral*

Email of person completing referral*

Client Info

Client Name*

First Middle Last

Date of Birth:*

Gender

SSN:

Race:*

Parent/Guardian Name

Phone Number

Insurance

At a minimum, please enter your primary insurance. If you have secondary insurance, please click the plus sign to the right of the fields to add your secondary insurance information.

Insurance Coverage Type (Medicaid, Medicare, Private Insurance, Uninsured)

Policy #

Address

Street Address & Apartment/Suite # City State ZIP Code

Client Phone:*

Client Email

Highest Grade Completed

Does the client give permission to be contacted via social media?

Yes

No

Social Media Contact Information

Social Media Platform

Username

Employment Status

Military Experience

Yes

No

Currently Pregnant:

Yes

No

Under Legal Guardianship

Yes

No

Reason for Referral:*

Check all that apply.

Symptoms and Behaviors/Risk Behaviors:*

Check all that apply.

Services Requested*

Check all that apply.

Is the client currently receiving outpatient mental health therapy?*

Yes

No

Is the individual currently receiving Peer Support Services?

Yes

No

Name of Peer Support Provider and preferred contact:

Treating Therapist Name:

First Last

Therapist's Phone Number

Therapist's Email

Is the individual currently receiving Target Case Management Services?

Yes

No

Name of Target Case Management Provider and preferred contact:

Preferred Available Day(s) for Initial Appointment

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred Time of Initial Appointment

Morning

Afternoon

Evening

General Comments

Untitled

First Choice

Second Choice

Third Choice

Name

This field is for validation purposes and should be left unchanged.