Article 31 Referral Form : Your Community : Who We Help : Abbott House

Today's Date

Month

/

Day

/

Year

Name

First Name *

Middle

Last Name *

Date of Birth

Current Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Email Address

Gender

Male
Female
Transgender Male
Transgender Female
Not Known

Race

American Indian
Asian
Black or African American
Hispanic
White
Other (Specify Below)

Other Race:

Marital Status

Single
Married
Divorced
Separated
Widowed

Referral Source:

Self
Other

If other, referral source name:

Language Preference

English
Spanish
Other

If other please specify below

Other Language

Why are you seeking services?

Please be sure to confirm any urgent medication/injection needs.

Services requested:

Family Therapy
Individual Therapy
Psychiatric Services
Psychological Services

Are you currently receiving treatment services anywhere else?

Yes
No

If yes, where?

Are you mandated to receive counseling/psychiatric services?

Yes
No

If yes, by whom?

Are you in a dangerous situation or at risk of harm?

Yes
No

If yes, please specify:

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Significant Events:

Describe any significant event that may have affected your current functioning (e.g. family deaths, abuse, trauma)

Significant medical / psychiatric history:

Mailing address if different from above:

Country

Address Line 1

City

State/Province

Postal Code

Primary Telephone

Ok to leave message?

Yes
No

Secondary Telephone:

In case of emergency contact:

First Name *

Last Name *

Relationship:

Emergency Contact Telephone:

Emergency Contact Address:

Country

Address Line 1

City

State/Province

Postal Code

Please upload your primary insurance card

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Please upload both front and back of card.

Upload your secondary insurance card if applicable

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Total monthly income:

Primary source of income at admission:

Number of Dependents:

Form completed by:

First Name *

Last Name *

Signature

Your typed name below serves as an electronic signature.

Article 31 Referral Form

Basic Demographics

Primary Payee / Insurance Information

Secondary Insurance Information

Income: