REFERRAL FOR SERVICES
Individual Demographics
The below questions pertain to the individual to be seen.
Name
*
First Name
Middle Name/Initial
Last Name
Preferred Name (if different)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Phone
*
Please enter a valid phone number.
Phone Number Type
*
Mobile
Home
Birthdate
*
-
Month
-
Day
Year
Date
Sex
*
Male
Female
Social Security Number (SSN)
*
Marital Status
Divorced
Legally Separated
Married
Single
Widowed
Partnered
Other
Anulled
Interlocutory
Polygamous
Individual's Email (If Individual has one)
example@example.com
Hearing Status
*
Deaf
Hard of hearing
Hearing
Preferred Language / Mode of Communication
*
English
ASL
Spanish
SimCom
Other
Contacts
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Please indicate your Referral Source by clicking the circle below.
*
BlueCross BlueShield of Tennessee ECF
BlueCross BlueShield of Tennessee BH
Amerigroup ECF
Amerigroup BH
TN DIDD
TN DCS
Other
Name of Person filling out this form.
*
First Name
Last Name
Your Phone Number
*
-
Area Code
Phone Number
Your Email (if we have questions)
*
example@example.com
Primary Care Provider (PCP)
*
First Name
Last Name
PCP Address (optional)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PCP Phone
-
Area Code
Phone Number
PCP Fax (optional)
-
Area Code
Phone Number
PCP Email
example@example.com
Residential Provider
Same as Emergency Contact
Same as Emergency Contact
Residential Provider's Name:
*
First Name
Last Name
Residential Provider's Phone Number:
*
-
Area Code
Phone Number
Residential Provider Email Address:
*
example@example.com
Back
Next
I/DD Range
Mild
Moderate
Severe
Individual's Information
The below pertains to the Individual to be seen
Chief Complaint
*
Please list the primary symptom behaviors
Reason for Referral:
*
Service(s) you would like us to provide
History of the Problem:
*
When did it start? What has been done in the past?
Diagnosis:
*
Please list all diagnoses currently active
Back
Next
Please answer all that apply
Leave blank if not applicable
Psychiatrist Name:
Psychiatrist Phone Number:
Therapist or BA's name:
Therapist or BA's Phone Number:
Conservator's Name (If none, enter NA):
*
Conservator's Phone Number (If none, enter NA):
*
Representative Payee (If applicable):
SOS Coordinator Name:
Representative Payee phone number:
SOS Coordinator phone number:
Is the individual enrolled in ECF Choices?
*
Yes
No
Does the individual have Medicare Coverage?
*
Yes
No
Does the individual have Medicare Advantage Coverage?
*
Yes
No
Does the individual have Medicaid Coverage?
*
Yes
No
Does the individual have Commercial Insurance Coverage?
*
Yes
No
Is DCS the Payor?
*
Yes
No
Primary Insurance*:
*
Is DIDD the Payor?
*
Yes
No
Insurance Identification Number*:
*
Please upload the front of the Primary insurance card
Browse Files
Front of card
Cancel
of
Please upload the back of the Primary insurance card
Browse Files
Back of Card
Cancel
of
Does individual have a secondary insurance?
*
Yes
No
Please upload a copy of the front and back of any other insurance cards
Browse Files
Cancel
of
Services requested
*
Skills Training Group
Individual Therapy
Psychiatric Evaluation and Management
Assessment
Consultation
Upload PCSP, ISP or current treatment plan
*
Browse Files
Cancel
of
Upload Medication List
*
Browse Files
Cancel
of
Current Medications
Which medications is individual currently using?
Drug Allergies
*
type NKDA if none
Previous psychological or psychiatric evaluation/BSP
Browse Files
Cancel
of
Submit
Should be Empty: