Referral Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Today's Date *DateFull Name *FirstLastDate of Birth *Marital Status: *MarriedNever MarriedSeparatedDivorcedRemarriedWidowedRace: *WhiteBlack/African AmericanAsian/Pacific IslanderAmerican IndianOtherEthnicity: *HispanicNon HispanicWhat is the client's primary language?EnglishSpanishOtherSex: *MaleFemaleOtherVeteran:YesNoSocial Security Number:SSNType of Insurance or Payment MethodMedicaid InsuranceCommercial InsuranceSelf-PayUnsureType of Insurance or Payment MethodInsurance Provider: *Insurance Number:School (if applicable):List Full Name of School and School District or N/ALast Grade or Degree Completed:Client's Phone Number *Client's Email: *EmailConfirm Emailexample@example.comHome Address: *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeReason for Referral: * you apply: contact When assessing the needs, risk, and behavior of presenting symptoms, the following factors are commonly considered. Please check all that apply: *School Suspension/Expulsion/Alternative School PlacementOut-of-Home PlacementVerbal AggressionArgues with Adults/AuthoritySignificant Peer Difficulties/Fights Peer/SiblingsFamily ViolenceBullies/ThreatensSuicidal Indentations/ThreatsPhysical AbuseProperty DestructionTruancyDefiant BehaviorsIQ TestingSelf-Injurious BehaviorsFire Setting BehaviorsDifficulty SleepingHomicidal IdeationsSexual AbuseStealsSubstance AbuseAlcohol AbuseDifficulty Following DirectionsNeuropsychological TestingIEP PlanBED Plan504 PlanMedication ManagementCourt-MandatedOtherDoes the client currently use nicotine or tobacco products? *YesNoIf yes, please specify (e.g., cigarettes, vaping, chewing tobacco):Parent/or Legal Guardian (if applicable):FirstLastParent/or Legal Guardian Emailexample@example.comPrimary Phone:Parent/or Legal Guardian phoneAlternative Phone:Parent/or Legal Guardian alternative phonePlease indicate whether the contact information above is for the client’s legal guardian or biological parent.Legal GuardianBiological ParentOtherIf you are not the biological parent of the child, can you provide one or more of the following documents to verify legal guardianship?A copy of the child’s birth certificate showing your nameA legal custody agreementA court order establishing guardianshipA notarized power of attorney for guardianshipAdoption paperworkAffidavit of guardianshipFoster care placement documentsSchool enrollment forms listing you as guardian (may be used in conjunction with another document)NoneWhat is the legal guardian/biological parent preferred language?EnglishSpanishOtherName of Person Submitting Referral Form: *FirstLastRelation to the client: *EX: Parent, Relative, Spouse or Professional SupportIndividual or Agency: *Write self-referral if you are referring your child or guardian. Otherwise, please list the name of the company or school you work for.Referral Source Phone Number: *Referral Source Email: *example@example.comFor a minor client, was the Parent or Legal Guardian notified of this referral?: *YesNoN/A; Client is over 18 or does not have a guardianDoes the Client Receive Services From Another Mental Health Provider? (If so, they need to be discharged from their current provider) : *YesNoAre the Services Currently discontinued?YesNoHas the client been hospitalized or participated in a Partial Hospitalization Program (PHP) or Intensive Outpatient Program (IOP) within the last 30 days? *YesNoClients Primary Care Provider Name:Which Community Health Ohio staff assisted or referred you to our program? Please list their full name and office location.Next Steps with Community Health AllianceSubmitting a referral onlyI’d like to schedule an appointment nowWhich of these weekdays works best for an intake appointment?MondayTuesdayWednesdayThursdayFridaySelect one or multiple available timeslots for an intake appointment.9:00 A.M.10:00 A.M.11:00 A.M.12:00 P.M.1:00 P.M.2:00 P.M.3:00 P.M.4:00 P.M.5:00 P.M.6:00 P.M.7:00 P.M.8:00 P.M.Where would you like your appointment to take place?At the officeVirtuallyAt your homeAt your school/in communitySubmit
