Clinician Referral Form Now Hiring State-Wide Make A Referral Areas We Serve Frequent Questions Make A Payment Referrer's InformationClinician's Name* First Last Clinician's Phone Number*Clinician's Email Address* Intake, Assessment, Treatment Plan Needed?* No, I WILL BE COMPLETING ALL 3 MYSELF Yes. I need someone to complete all 3 for me I need someone to complete INTAKE ONLY I need someone to complete ASSESSMENT and TREATMENT PLAN ONLY Potential Client InformationPotential Client's Name* First Name Last Name Potential Client's DOB (preferred) or Approximate Age Below Month Day Year Approximate Age*Please enter a number from 1 to 120.Parent / Legal Guardian (if applicable) Second Legal Guardian (if applicable) Primary Phone*Secondary PhoneAdditional PhoneEmail Location (City/Town)* Problem(s) / Behavior(s) / Situation(s)Significant HistoryInsurance Provider Aetna Aetna Coventry Aetna Medicaid Alliance Coal Allied National BlueCross Blue Shield ChampVA Cigna EAP Services Cigna Health and Life Insurance Co. Edison Health Solutions GPA Group Benefit Services (GBS) Health Smart Healthcare Highways HealthCare Solutions Group HealthChoice HealthScope HealthSmart HealthSmart Benefit Solutions Humana Military HumanaChoice PPO Humana Medicaid Humana Medicare Medica Medicaid Medicare (original) Medicare (supplemental plan) Meritain Health Oklahoma Complete Health OPTUM VA The Kempton Group Tricare East UMR - Wausau/UHIS United Health Care/United Behavioral Health UHC Medicare WebTPA Other ID #* School Information (if applicable)GradePlease enter a number from 0 to 12.Teacher(s)Is student on an IEP? Other InformationStaff Member Preference Name* Case # Upload DocumentsMax. file size: 50 MB.EmailThis field is for validation purposes and should be left unchanged. Δ