Home
What We Do
Meet the Team
Make A Referral
FAQ

What We Do
Meet the Team

What We Do
Meet the Team

Make A Referral
FAQ

Make A Referral
FAQ

Therapist Referral Form

Submit Referral Below

Master's-Level Therapy Referral Form

Referral Form Fluent

What type of Claim is this?

State Fund

Self Insured

Referral Type

Behavior Health Intervention (BHI)

Accepted Mental Health Diagnosis on Claim (MH)

Has this worker completed BHI sessions previously with a different Provider?

Yes

No

Unknown

If "Yes," provide approximate dates of service and provider name:

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 (Specify below)

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.

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.

Preferred method of treatment:

In-person

Telehealth

No preference

*** Limited in-person sessions are available at this time

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.)

Upload Documents

Drop a file here or click to upload | Max 10mb

Thank you for the referral. Please allow 3 business days for us to process the referral request.

Get in Touch With a Counselor Who Can Help

Get Started

What We Do
Meet the Team
Make a Referral
FAQ
Articles

What We Do
Meet the Team
Make a Referral
FAQ
Articles

Questions? Connect With Us

Basic Contact Footer

Name

Email

Phone

Message

Connect With Us

1801 D St. Ste. 4
Vancouver, WA 98663

Number: (253) 449-8033

Fax: (360) 566-2533

Get Started

What We Do
Meet the Team
Make a Referral
FAQ
Articles

What We Do
Meet the Team
Make a Referral
FAQ
Articles

Resources

© Copyright 2024. All rights Reserved.