Community-Based Services Referral/Admission

Date*
Office Locality*
Referred by*
Relationship*
Phone Number
Email Address
Indicate Needed Services (Check All That Apply)
- Mental Health Outpatient Counseling
- Family/Parent Engagement Services
- Group Therapy (Specify Group in Reason for Referral)
- Intensive In-Home
- Intensive Care Coordination (ICC)
- Parental Capacity Evaluations
- Substance Abuse Outpatient Counseling
- Supervised Visitation
- Capacity Evaluation (ID/DD Individuals Only)
- Therapeutic Consultation (ID/DD Individuals Only)
- Therapeutic Mentoring
- Parent Education Classes
Service Delivery Preference
Service Delivery Preference*
- In-Person
- Telehealth / Virtual (Applicable Services Only)
- Either (No Preference)
Client/Referral Information
Client First Name*
Client Last Name*
Preferred Name
Date of Birth*
Gender*
SSN*
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Email Address*
If Applicable
Legal Guardian
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone Number
Email Address
Biological Parent #1
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone Number
Email Address
Biological Parent #2
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone Number
Email Address
Foster Parent #1
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone Number
Email Address
Foster Parent #2
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone Number
Email Address
Current Services & Providers
Name Agency Address Phone Number Email Address
List diagnoses by history:
List any medications:
Insurance Information *In an effort to expedite verification, please email a copy/photo of the front and back of your insurance card to counselingreferral@depaulcr.org.
Put N/A if Not Applicable
Insurance Type
- Medicaid MCO
- Private Insurance
Name of Insurance Provider
Member ID:*
Policy holder Name/ Billing contact:*
Phone Number of Insurance Provider (Number found on back of Insurance Card)*
Reason for Referral
Symptoms/Behavior/Concerns:*
How Did You Hear About Us?
Example: Insurance Company, Google, Social Media, Etc.
For Office Use Only
Authorization Number
Co-Pay
Number of Auth. Sessions
Dates of Eligibility
For Agency Disposition Use Only
- Accepted
- Declined
Reason (if declined)
Staff Assigned
Date Assigned
CAPTCHA

To check on the status of your submitted referral, please contact the Director of Community-Based Services directly at JPoston@depaulcr.org.

Name	Agency	Address	Phone Number	Email Address

Community-Based Services Referral/Admission

Service Delivery Preference

Client/Referral Information

If Applicable

Legal Guardian

Biological Parent #1

Biological Parent #2

Foster Parent #1

Foster Parent #2

Insurance Information *In an effort to expedite verification, please email a copy/photo of the front and back of your insurance card to counselingreferral@depaulcr.org.

Reason for Referral

How Did You Hear About Us?

For Office Use Only

For Agency Disposition Use Only