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
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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
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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
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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
*
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of
Upload Medication List
*
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of
Current Medications
Which medications is individual currently using?
Drug Allergies
*
type NKDA if none
Previous psychological or psychiatric evaluation/BSP
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of
Submit
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