Specialized Outpatient Services

Referral Form

Use this form to refer a client for services at S.O.S. Counseling. Select one or more services below. All information is kept confidential and handled in accordance with HIPAA guidelines.

1 Referral Information

Date *

Client Name *

Client Address

Referral Source (Name and Agency) *

Referral Phone

Referral Fax

Referral Address

2 Client Information

Client Date of Birth

Age

Gender

Residing With (Name and Relationship)

Address

Contact Number *

4 Insurance / Payment Information

Type of Insurance

Medicaid — Total Care Medicaid — UHC Medicaid — Healthy Blue (Auth needed) Other

Policy #

Group #

Insurance Phone #

By submitting this form, you confirm that you have authorization to refer this individual for services. All information will be kept confidential.

Referral submitted successfully!

Referral Form

1 Referral Information

2 Client Information

3 Service Information

4 Insurance / Payment Information

5 CTA Intake Information