Agency Referral Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Section 1: Who is completing this form?Who is completing this form? *SelfParent / Guardian referring a childProfessional / Agency referring a patientSection 2: Referrer Information (If Professional / Agency)This Section will only appear if you are a Professional or Agency referring a patient.Name of Person Submitting Referral: *FirstLastOrganization / Agency / School: *Referrer NPI (If applicable):Phone Number:Email Address:Were you referred by a Community Health Alliance (CHA) employee?YesNoIf yes, Employee Name:Section 3: Client DemographicsLegal Name: *FirstLastPreferred Name (If applicable):Date of Birth: *MM/DD/YYYYSex Assigned at Birth: *MaleFemaleGender Identity: *MaleFemaleTransgenderNon-binaryPrefer not to answerRace *— Select Choice —WhiteBlack/African AmericanAsian/Pacific IslanderAmerican IndianOtherEthnicity *— Select Choice —HispanicNon-HispanicPrimary Language *— Select Choice —EnglishSpanishOther Chief services have Are you currently homeless / Do not have a primary home address? *YesNoPrimary Home Address: *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSection 4: Guardian & Contact InformationAre you or the person being referred a minor / require a guardian? *YesNoParent / Legal Guardian Name: *FirstLastRelationship to Client: *Is the client in the custody of anyone other than a biological parent? *YesNoParent/Guardian Primary Phone: *Alternate Phone:Parent/Guardian Email:Preferred Method of Contact: *Phone CallText MessageEmailWas the Parent/Legal Guardian notified of this referral? *YesNoSection 5: Clinical Intake & InsurancePayment Method: *MedicaidCommercial InsuranceSelf-PayUnsureInsurance Provider Name: *Insurance ID / Member Number: *Does the client currently receive services from another mental health provider? *YesNoHas the client been hospitalized or in a PHP/IOP program within the last 30 days? *YesNoSection 6: Reason for ReferralPlease select all applicable symptoms or concernsMental Health / Emotional:Depressed Mood / SadnessAnxiety / Excessive WorryMood SwingsHallucinations / DelusionsDifficulty SleepingTrauma Responses / PTSDBehavioral / Conduct:Verbal AggressionPhysical Aggression / FightsProperty DestructionDefiant / ArguesTruancy / School SuspensionFire SettingSubstance Use:Alcohol Misuse / DependenceIllicit Substance UsePrescription MisuseRisk / Safety Concerns:Suicidal Ideation / ThreatsHomicidal IdeationSelf-Injurious BehaviorPhysical / Sexual AbuseFamily ViolenceEducational / Cognitive:IEP/504/BED Plan RequiredNeuropsych/IQ Testing NeededDifficulty Following DirectionsBrief Narrative / Chief Complaint: *Section 7: Scheduling Preferences (For Self/Parent Referrals)Preferred Location (Check all that apply):OfficeVirtual (Telehealth)HomeSchool/CommunityWhich locations are you interested in receiving services from? *Family Solutions – CincinnatiFamily Solutions – ColumbusFamily Solutions – Bedford HeightsFamily Solutions – LorainSojourner Recovery ServicesTransitional Living Center (TLC)UnsurePreferred Days for Intake AppointmentMondayTuesdayWednesdayThursdayFridayPreferred Times for Intake Appointment:9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PM8:00 PMPlease note, this does not schedule your appointment. It simply lets us know when best to schedule for you!Submit
