Behavioral Health
Referral

Client Information:

Name:*
Date of Birth:*
 / 
 / 
Social Security Number:*
Sex:*
Address:*
Phone:*
-
E-mail:*
Have you been evaluated for (Please check ALL that appy:*
Living arrangement:*
Marital status:*
Primary spoken language:*
Employment status:*
Why are you seeking services?*
Which of our locations would you prefer to receive services at (not all services are offered at each location):*

Insurance Information:
For Medicaid, please fill out the insurance name and MMIS #.
For Caresource, please fill out the insurance name, insured ID, and MMIS #.
For Private Insurance and Medicare, please fill out ALL the blank spaces.

Primary insurance name:*
Insured ID:*
Group ID:*
MMIS# (If applicable):
Subscriber name:*
Subscriber DOB:*
 / 
 / 
Subscriber address:*
Secondary insurance information:

Emergency Contact Information:

Emergency contact name:*
Relation to Client:*
Emergency contact phone:*
-
Type:*

Guardianship Information:
A guardian is defined as someone other than the client that is legally responsible for them. Guardian(s) can be biological or adoptive parent(s) of minor children (under the age of 18) or court appointed (if over 18) which can include agencies, parents, or extended family. If applicable, please provide the guardian(s) information AND legal documentation stating the guardianship arrangement from the courts:

Guardian name:*
Guardian phone:*
-
Relation to client:*

Referral Information:

Name/Agency/Other: *

Crisis Information:

Do you believe the client is in imminent danger of harming themself or others?*

If yes, please know you can call 911 or go to your nearest emergency room as we are NOT a crisis center.

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Worthington Campus

445 E. Dublin Granville Road
Worthington, OH 43085

614-436-7837

info@iamboundless.org

Newark Campus

140 W. Church Street
Newark, OH 43055

740-334-4056

info@iamboundless.org

West Carrollton Campus

700 Liberty Lane
West Carrollton, Ohio 45449

937-247-2400

info@iamboundless.org