Behavioral Health Request Form

Contact Information:

Referral Date: (mm/dd/yyyy)
Contact Name:
Agency:
Address:
City, State, Zip Code:
Work Phone: Email:

If applicable:

Case Manager's Name:
Phone: Email:
Fax:

Client Services Information

Services Requested:
IIC Clinically Licensed Therapist
Behavioral Assistant
IIC Masters Level Therapist
Mentor
Other:

Numbers of Hours:
ABS Number:
Authorization Number:
Medicaid Number:
Medicare Number:
Flex Funds: Yes No

Client History:

Diagnosis:
Axis I:
Axis II:
Axis III:
Axis IV:
GAF:
Client Information:

Other Comments:

Client Information:

Client Name:
Address:
City, State, Zip Code:
Home Phone:
Birthdate: (mm/dd/yyyy) Sex: Male Female
Social Security Number:

Lives with:
Contact Name:
Address:
City, State, Zip Code:
Home Phone: Work Phone:
Cell Phone: Email:
Relationship to Client:

Name:
Relationship to Client:
Address:
City, State, Zip Code:
Home Phone: Work Phone:
Cell Phone: Email:

Insurance Information (For secondary insurance clients only)

Insurance Name:
Address:
City, State, Zip:
Policy Number:
Representative:
Rep. Number:
Fax Number:

 Name:     Email: 

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