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Submit a Referral
Referral Date
*
Month
First name
*
Last name
*
Date of Birth
*
Month
Preferred Language
*
Address
*
Insurance Plan
*
Aetna
Blue Cross Blue Shield
Cigna
AHCCCS
Mercy Care
UnitedHealthcare *Medicaid Plan
UnitedHealthcare *Commercial Plan
Optum
Private Pay
Insurance Member ID
*
Policy Number
Phone
*
Guardian/Placement Name
Guardian/Placement Language
Guardian/Placement Phone *Leave blank if same as above
PCP Clinic/Agency
Name of PCP
PCP Phone
Referral Source
*
Health Plan
PCP
Behavioral Health Provider
Community Partner
Hospital
Self
Referring Clinic/Agency
Referring Provider
Referring Provider Email
Referring Provider Phone
Request for Services
*
Individual Therapy
Family Therapy
Group Therapy
Other
Service Modality
*
Cognitive Behavioral Therapy
Dialectic Behavioral Therapy
EMDR Therapy
Art/Play Therapy
Somatic Therapy
Neurofeedback
Trauma Therapy
Substance Abuse Therapy
Grief Therapy
LGBTQIA+
Identity Issues
Other
Other
Reason for Referral
*
Provider Type
*
Male
Female
No Preference
Referral Documents
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Insurance Card *Front & Back
Upload File
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