Refer a Client

Behavioral Health Referral Form

About you

To ensure we provide the best possible support, kindly fill out this section with accurate and detailed information about yourself.

Your Name

Your last name

Your Organization (if applicable)

Your title (if applicable)

Your email

Your phone number

About the Client

To ensure we provide the best possible support, kindly fill out this section with accurate and detailed information about the person you are referring.

Client’s Name

Client’s last name

Client’s email

Client’s phone number

Client’s Date of Birth

Client’s Gender

Client’s Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Is Client full time student?

Yes

Not sure

Is Client disabled?

Yes

Not sure

Is Client a veteran?

Yes

Not sure

Client’s Insurance Provider

Client’s Insurance Policy Number or Medicaid ID Number

Has the Client received any of these services, currently or in the past?

Yes

Not sure

Brief Description of Behavioral Health Needs

Preferred time for follow-up contact

Morning

Afternoon

Consent and Authorization

By submitting this referral form, I confirm that I have obtained the necessary consent from the client to share their personal and medical information with Regional Management Care, Inc. I authorize Regional Management Care, Inc. to use this information for the purpose of evaluating, contacting and providing appropriate services. I understand that this information will be handled in compliance with HIPAA and applicable privacy laws.

I agree

About you

About the Client

Consent and Authorization

Thank you.

Regional Management Care, Inc.
-
4970 W Atlantic Blvd. Margate, FL 33063
Ph. (954) 474-7373

Refer a Client

About you

About the Client

Consent and Authorization

Thank you.

Regional Management Care, Inc. -4970 W Atlantic Blvd. Margate, FL 33063 Ph. (954) 474-7373

Regional Management Care, Inc.
-
4970 W Atlantic Blvd. Margate, FL 33063
Ph. (954) 474-7373