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What We Do
Meet the Team
What We Do
Meet the Team
Make A Referral
FAQ
Make A Referral
FAQ
Therapist Referral Form
Master’s-Level Therapist Referral Form
Referral Form
What type of Claim is this?
State Fund
Self Insured
Referral Type
Behavior Health Intervention (BHI)
Accepted Mental Health Diagnosis on Claim (MH)
Employer
Date of Injury
Claim #
Client First Name
Client Last Name
Client Date of Birth
Client Telephone #
Client Email Address (used for scheduling)
Client Address
Your Relationship to Client
VRC
Attending Provider
Medical Assistant
Other
Other
Your Name
Your Phone
Your Email
All Accepted and Denied Conditions (include ICD codes)
For BHI referrals, did the attending provider indicate approval / recommendation?
Yes
N/A - this is not a BHI referral
*** Please attach completed questionnaire, APF, or chart note.
For MH referrals, has treatment been authorized?
Yes
N/A – this is not a MH referral
*** 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?
Yes - I have spoken with the client about this referral and they are expecting a call from the therapist (or interpreter) to schedule.
Preferred method of treatment:
In-person
Telehealth
No preference
*** Limited in-person sessions are available at this time
Primary Language
If English is second language, is it preferred that a therapist who speaks the client’s primary language be assigned?
N/A
Yes
No preference
Name and Contact Info for Preferred Interpreter*
* If we don't have a therapist who speaks the primary language, please provide the contact info for an interpreter here.
Claims Manager Name
Claims Manager Phone #:
Vocational Rehabilitation Counselor
VRC Phone #
Attorney Rep Name
Attorney Telephone #
Attending Provider Name
Attending Provider Telephone #
Attending Provider Fax #
Brief explanation of reason for referral (symptoms, situation/barriers, etc.)
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