Healing Transition Behavioral Health Services

Submit a Referral

Use this form to securely refer a client for services at Healing Transition Behavioral Health Services. This referral form is intended for healthcare providers, case managers, social workers, and other professionals.

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Referring Provider / Organization Name

Contact Person Name

Title / Role

Email Address

Fax Number

Organization Address

Client Full Name

Date of Birth (YYYY-MM-DD)

Gender

Client Email Address

Client Address

City, State, ZIP

Primary Language

Preferred Contact Method

Insurance Provider

Member ID / Policy Number

Group Number

Authorization Number (optional)

Primary Reason for Referral

Current Diagnoses / DSM-5 Codes

Current Medications

Relevant History / Background

Is the client currently at risk of harm to self or others?

Current Safety Plan in Place?

Additional Safety Notes

Has the client consented to this referral?

Release of Information on File?

Additional Notes / Special Considerations