Therapist Referral Form

Master’s-Level Therapist Referral Form
Referral Form
What type of Claim is this?
Referral Type
Your Relationship to Client
For BHI referrals, did the attending provider indicate approval / recommendation?
*** Please attach completed questionnaire, APF, or chart note.
For MH referrals, has treatment been authorized?
*** Please attach screen shot from CAC with the following psych codes authorized: 90832/90834/90837 (Therapy 30 min, 45 min, 60 min)
Conversation with client?
Preferred method of treatment:
*** Limited in-person sessions are available at this time
If English is second language, is it preferred that a therapist who speaks the client’s primary language be assigned?
* If we don't have a therapist who speaks the primary language, please provide the contact info for an interpreter here.
Maximum upload size: 52.43MB