Roots Wellness Adult Referral
This referral is for:
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Rule 25/Comp Assessment
SUD IOP Treatment
RootsREACH
Referent Information
First Name
*
Last Name
*
Company
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
Relationship to the Client
*
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Client Information
First Name
*
Middle Name
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security
*
Resides on Reservation?
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Yes
No
Reservation Name
Eligible for Indian Health Services?
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Yes
No
Gender Identity
*
Preferred Pronouns
*
Sexual Orientation
*
Living Situation
*
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone
*
Phone message ok?
*
Yes
No
Email
example@example.com
Preferred Method of Contact
*
Phone Call
Text
Email
Best Time to Contact
Reason for Referral
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Primary Concerns
*
Substances Used
*
Currently receiving Medication Assisted Treatment?
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Yes
No
If yes, what clinic?
Mental Health Diagnoses/Concerns
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Current Therapy/Treatment Services & Supports
*
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Funding/Payment Information
What is the planned payment method for services?
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Self-Pay
Insurance
Other
Does the client have insurance?
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Yes
No
If yes, what type of insurance?
Commercial
PMAP
MA/Medicaid
PMI #
Insurance
Ucare
Medicaid/MA/PMAP
Preferred One
Henepin Health
Medica
Health Partners
BlueCross
Other
Policy Holder
Client
Parent/Guardian
Spouse/Other
Policy Holder Name
Policy Number
Group Number
Prior Auth Needed?
Yes
No
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