Registration/Referral Form
There are required areas in this form. Please fill out as much as possible and follow all directions below.
Referral Date
-
Month
-
Day
Year
Date
Client Name
*
First Name
Middle Name
Last Name
Marital Status
*
Married
Divorced
Widow/Widower
Single
Maiden Name if Married
Program to be enrolled into
*
Mental Health
Substance Abuse
Referral Source (if applicable)
First Name
Last Name
Referral Phone (if applicable)
-
Area Code
Phone Number
Referral Email (if applicable)
example@example.com
Parent/Guardian Name for Clients under the age of 18
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence
*
Home Phone (If home phone is cell, put that here. If unknown at time of referral put "UNK.")
*
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Is it ok to send you reminder text messages regarding appointments?
*
Yes
No
Is it ok to send you information via email?
*
Yes
No
Client Email (DMH requires an email unless the client refuses. If they refuse state "Refused." If you don't know the email, put "UNK" so we know to get it.)
*
example@example.com
Date of Birth
*
Age
*
Race
*
Social Security Number (if not know put "UNK". SSN will be needed before pre-auth can be sent to DMH.)
*
Gender
*
Male
Female
Living Situation (In own home, homeless, etc.)
*
Guardian required (If so put information. If none put "NONE.")
*
Preferred Language
*
Military Status
*
Type of Residence
*
School (if applicable)
Grade (if applicable)
Female
Are you pregnant?
Yes
No
What is your due date?
-
Month
-
Day
Year
Date
Do you have an OB/GYN? Who?
Drug Use
For IV and non-IV drug use.
Does the client currently use any non-prescribed drugs?
*
Yes
No
Type of drugs
Has the client used drugs in the past?
Yes
No
Last date drugs were taken, if applicable:
-
Month
-
Day
Year
Date
Tobacco Use
This includes all products that contain nicotine.
Does the client currently use any tobacco products or products that contain nicotine?
*
Yes
No
What type?
How often per day?
Tobacco Helpline Information accepted / declined by client?
Yes
No
Caffeine Use
Does the client drink or eat anything that contains caffeine?
*
Yes
No
What type?
How often per day?
Referral Reasoning
How did you hear about AWS?
*
Reason for referral/Reason for seeking services:
*
Insurance
Type of Insurance (If Medicaid, only the ID number is needed. If they do not know their number at time of referral put "UKN" in all boxes.)
*
Medicaid
BCBS
Medicare
Private Pay
Insurance Name
Customer ID #
Policy #
Group #
Responsible Party other than self :
First Name
Last Name
Date of Birth of Responsible Party
-
Month
-
Day
Year
Date
Requested Therapist (if applicable)
First Name
Last Name
Requested Case Manager (if applicable)
First Name
Last Name
Staff Email if being submitted by staff (if applicable)
example@example.com
Attachments
If there are any attachments that need to be sent, please add them here
Attachments (If there is more than one file that needs to be attached, just click on the "Browse Files" button again you can add more.)
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Submit this referral to AWS Behavioral Health
Once you have finished this form, please click on the "Submit" button below.
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