Referrals

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	Request for Behavioral Health (Mental Health or Substance Use) Assessment and/or Linkage with Family Service League, Inc.

Date

Practice Name

Practice Zip

Requestor's Contact Information

First Name

Last Name

Callback Number

Email Address

Referral Type

Mental Health

Substance Use

Mental Health & Substance Use

Referral Reason

Does Patient Need to be Assessed Immediately (urgent/imminent risk)?

Is Patient a Minor (under 18 y.o.)?

Parent/Guardian Information:

Parent/Guardian First

Parent/Guardian Last

Parent/Guardian Relation

Patient's Information

First Name

Last Name

Address

City

State

Zip

SSNo

DOB

Gender

Race

Marital Status

Language

Mobile Phone

Home Phone

Payer Information

Funding Source

Insurance Co Name

Policy Number

Is Patient the Insured?

If patient is not the policyholder complete below:

First Name

Last Name

Insured Relationship

DOB

Submit

Request for Behavioral Health (Mental Health or Substance Use) Assessment and/or Linkage with Family Service League, Inc.

Requestor's Contact Information

Parent/Guardian Information:

Patient's Information

Payer Information

If patient is not the policyholder complete below: