[cfdb-html form=”referral form” limit=”10″ orderby=”submitted desc”]

HELP Behavioral Counseling and Psychological Testing
How did you find HELP?
Who are you referring?
Date: DOB: Gender:
Client’s Name:
Street address:
City: State: Zip:
Home: Cell:SS#:
Referred by:
Phone #: Fax #:
Agency Name:
Psychological Testing And Evaluation Requirements:
Referring MD name: Phone #
Insurance Info:
Primary Insurance Name:
Medicare#: ID #: Group #:
Secondary Insurance:
ID #: Group # Primary Insured:
Insured Name: DOB: SS #
Primary Physician Name: Phone:
Psychiatrist Name: Phone:
Psychiatric Medication:
Support System:

Reason for referral: ${textarea-608-reason}
Place of Service: Email: Special Needs:
HELP Staff Use Only:

1st Provider Assigned: Date Sent:
2nd Provider Assigned: Date Sent:
Subscribe to Newsletter Name: Email:

———– End Record ———–

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