REFERRAL INFORMATION
Page 2
FAMILY MEMBERS
CURRENTLY LIVING IN HOUSEHOLD AND RELATIONSHIP TO CLIENT:
NAME:
___________________________________
RELATIONSHIP: _________________________
NAME:
___________________________________
RELATIONSHIP: _________________________
NAME:
___________________________________
RELATIONSHIP: _________________________
NAME:
___________________________________
RELATIONSHIP: _________________________
NAME:
___________________________________
RELATIONSHIP: _________________________
IS CLIENT VIOLENT OR
HAVE POETNTIAL FOR VIOLENCE? __________________________
IS THERE HISTORY OF
VIOLENT BEHAVIOR? ____________________________________________
IS CLIENT ON ANY
MEDICATION? _____ IF SO, WHAT KIND? ______________________________
WHAT IS EXPECTED DATE OF SERVICE TERMINATION? _________________________________
BILLING
INFORMATION
AGENCY/INDIVIDUAL
RESPONSIBLE FOR PAYMENT: _____________________________________
SEND INVOICES TO: _____________________________________________________________________
_____________________________________________________________________
MEDICAID/INSURANCE ID
NUMBER: _____________________________________________________
PERINENT INFORMATION:
DEDUCTIBLE $_______ CO-PAY $_______ % SPLIT______________
MEDICAID
AUTHORIZATION: _ _ _
_ _ _
_ _ _
_ _ _
_ UNITS: _____
PERIOD COVERED: ___/
_____/ _____ TO ____/ _____/ ____
COPY OF INSURANCE
CARD: ______ON FILE ______SUBMIT AT INITIAL SESSION
DOES REFERRING
WORKER/AGENCY REQUIRE COPEIS OF PROGRESS NOTES?
Y___ N ___
IF YES, TO WHOM AND WHERE SHOULD PROGRESS
NOTES BE SENT?
__________________________________________________
__________________________________________________
___________________________________________________
REFERRAL COMPLETED
BY: ________________________________________ DATE: ___________
BILLING INFORMATION
CONFIRMED BY: ____________________________DATE: ____________