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Paso a Paso

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A. REFERENCE
B. DEMOGRAPHICS
B1. Who
B2. Contact Information
Emergency Contact Information

Emergency Contact is someone who knows your medical history and how to contact family and friends in the case of an emergency.

1
B3. Stats
B4. Choices
Communication Preferences
B7. Primary Care Physician
C. MENTAL HEALTH INFORMATION
C2. Symptoms
(2) Click desired SYMPTOM to SELECT it. To SELECT Multiple SYMPTOMS HOLD DOWN [Ctrl] Key on your keyboard and SELECT each one.
C3. Current Diagnosis
(2) Click desired DIAGNOSIS below to select it. To SELECT Multiple Symptoms HOLD DOWN [Ctrl] Key on your keyboard and SELECT each one.
C4. Previous Mental Health Treatments and/or Services Received

Please use Approximate Dates, if you don't know the Exact Dates.

D. SERVICES
D1. Services Being Requested
D2. Professional Being Requested
D3. Are any of your family members currently receiving services at Behavioral Work?
E. EXTERNAL SERVICES
E1. Are you receiving any other Medicaid-related services from another agency?
F. INSURANCE INFORMATION

I understand that I must disclose all insurance coverage. If failure to disclose results in a denied claim, I will be financially responsible for the services provided.

Entiendo que debo revelar toda la cobertura de seguro. Si la falta de revelar los resultados en una reclamación denegada, seré financieramente responsable de los servicios prestados.

Primary Insurance Policy Holder Information
Personal Information
Contact Information
G. Are you submitting this referral for YOURSELF, or are you the PARENT or LEGAL GUARDIAN?
H. ANY OTHER CONCERNS YOU MIGHT HAVE
I. DISCLAIMER

This information has been disclosed to you from records whose confidentiality is protected by state law. State law prohibits you from making any further disclosure of such information without the specific written consent of the person to whom such information pertains or as otherwise permitted by state law. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

Renucia de Reponsibilidad

Esta información ha sido revelada a usted de los expedientes cuya confidencialidad está protegida por la ley estatal. La ley del estado le prohíbe hacer cualquier divulgación adicional de tal información sin el consentimiento por escrito específico de la persona a quien dicha información pertenece, o según lo permitido de otra manera por la ley del estado. Una autorización general para la divulgación de información médica o de otra forma no es suficiente para este propósito.