Assessment/Referral Request

Appointment or Referral
Is this appointment request or referral for you or someone else?

Personal & Contact Information

Requesting an appointment for yourself
Your Full Name

First NameLast Name
Gender
Date of Birth
Date of Birth

MonthDayYear
Phone Number
A valid phone number is required so our team can contact you regarding scheduling and next steps.Format: (000) 000-0000.
Additional Authorized Contact Methods
Email Address
Provide an email address if you would like to receive a copy of your submission and additional communication updates.
Do you need a handicapped-accessible room?

Personal & Contact Information

Requesting an appointment on behalf of another person
Your Full Name

First NameLast NameSuffix
Phone Number
A valid phone number is required so our team can contact you regarding scheduling and next steps.Format: (000) 000-0000.
Additional Authorized Contact Methods
Email Address
Provide an email address if you would like to receive a copy of your submission and additional communication updates.
Relationship Information

Please complete the information below for the person seeking services.
What is your relationship to the person seeking services?
Relationship, Other (Please describe)
Does this client have a legal guardian?
Who is the client's legal guardian?
Legal Guardian's Name:
Legal Guardian's Contact Information:
Client Information

Please complete the information below for the person seeking services.
Person Seeking Services

First NameLast NameSuffix
Date of Birth
Date of Birth

MonthDayYear
Gender
Does this client need a handicapped-accessible room?
Documentation

If you have any of the following documents for the individual being referred, please upload them using the "Browse Files" button below.
Documents may include the following:
- Comprehensive Clinical Assessment
- Medical History/Record
- Release of Information Form
- Applicable lab work
- Medication List
- Progress Notes
- Medication Administration Record (if applicable)
- Discharge Summary and/or Instructions
- Legal Guardian Consent Form (if applicable)
- TB skin test results from the past 30 days
Please note: This documentation portal and referral form are encrypted in compliance with HIPAA regulations to ensure client security and confidentiality. If the required documentation is incomplete or does not provide sufficient information for a comprehensive assessment, we will schedule a phone interview with the client prior to program acceptance to ensure a smooth transition and avoid any delays upon arrival.
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Final step before submitting your appointment request
How did you hear about us?
Other (Please specify):
Anything else we should know? (Please share any additional information that may help our team prepare for follow-up. Do not include detailed medical or emergency information.)

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Appointment or Referral

Personal & Contact Information

Personal & Contact Information

Relationship Information

Client Information

Documentation

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