Therapist Referral Form

Submit Referral Below

Press the “submit” button once and wait up to 60 seconds – especially if you are uploading documents. Thank you for your patience.

Master’s-Level Therapist Referral Form
Referral Form
What type of Claim is this?
Referral Type
Has this worker completed BHI sessions previously with a different Provider? *
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?
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.
Preferred method of treatment:
*** Limited in-person sessions are available at this time

Maximum file size: 52.43MB

Press the “submit” button once and wait up to 60 seconds – especially if you are uploading documents. 

Thank you for your patience.

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