Referral for Adult Services Submission IDHiddenInternal request? Internal Transfer Additional Services Request HiddenWas client accepted for services? Yes No Client was placed on a 30 day wait list HiddenStatus of denied referral Client was referred to another provider/agency Client refused services Client did not respond to offer of services Client was out of service area No provider available Agency does not accept client's insurance No active insurance Client already had a provider in place HiddenBHP Accepting Case HiddenNotes for ProvidersThis field will show on the waitlist report; use only for notes we want to share with providers for matching purposes.HiddenAdmin Only NotesThis field is for the Intake Coordinator to add notes for closure.Anyone may complete a referral form for themself or another person; this form does not need to be completed by a doctor's office or specialist.Your Email* Your Name* First Last Your Relationship to Client* Your PhoneClient InformationClient Name* First Last Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender Male Female Language Needs Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County* Email* Phone*Insurance InformationPrivate Pay I do not want to bill an insurance plan for services; I will pay the private pay rate for services. Does the client have Kentucky Medicaid?* Yes No Medicaid Number* Name of Managed Care Company*Select OneAetna Better Health of KentuckyAnthem MedicaidHumana MedicaidUnited Healthcare MedicaidWellcareMedicaid OnlyPassportMember Identification Number* Is the client covered by Medicare?* Yes No Does the client have commercial insurance coverage?* Yes No Name of Primary Insurance Company* Member Identification Number* Primary Insured's Name if other than Client* Primary Insured's Birthdate*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does the client have a secondary commercial insurance coverage? Yes No Name of Secondary Insurance Company Member Identification Number* Secondary Insured's Name if other than Client Secondary Insured's BirthdateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is the client covered by two insurance plans?* Yes No Guardian InformationDoes the client have a legal guardian?* Yes No Name First Last Relationship to client PhoneIs the guardian's address different than the client's address? yes no Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reason for ReferralPlease tell us about your concerns and how we may help.*providers and hospitals please provide the diagnosisPlease indicate the services you are interested in receiving:* Individual Counseling Couples Counseling Family Therapy Community Support Telehealth In-person services In-home services In-office services I don't know yet, I would like to talk with someone first Please indicate any services the client is currently receiving: Inpatient psychiatric hospitalization Intensive out-patient therapy Case Management Services Medication Therapy Other Other Services:* Is this referral a follow up to a discharge from a mental health or chemical dependency hospitalization? Yes No What is the date of the discharge from the hospital MM slash DD slash YYYY Some of our home-based therapists have allergies. Please mark if any of the following are in your home. Dog(s) Cat(s) Bird(s) Cigarette smoking Please tell us the days and times you are available to meet for servicesDo you want a specific provider for your services? Yes No What is the name of the provider you are requesting?Attach photos of front and back of insurance cards Drop files here or Select files Max. file size: 32 MB. HiddenDate of initial BHP appointment MM slash DD slash YYYY HiddenTCM Accepting Case HiddenDate of TCM appointment MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.