Rhema Referral Form

Name:

Prefix First Name Last Name

Date

Month Day Year

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Email Address:

Email

Phone Number

Area Code Phone Number

Date of Birth:

Sex:

Age:

Place of Employment:

School:

Referred by:

Authorization #:

Parent or Guardian (In case of Minor):

Presenting Issues

(Please check all that apply)

Individual Counseling Marriage Counseling Family Therapy Group Therapy Play Therapy School Problems Medication Management

Issues

Current and Past Medications:

Previous Hospitalization/Treatment

Insurance:

CoPay:

Insurance / Medicaid Number:

Best time to Call:

Session:

Authorization Dates From:

Authorization Dates To:

CoPay:

First Intake Appt. Worker:

Date of Intake:

S/NS:

Second Intake Appt. Worker:

Date of Intake:

S/NS:

Assigned Therapist:

Date of Assigned: