Behavioral Health Intervention Services Referral Form

We are happy to accept referrals and questions. Please contact us at: 319-286-4531 or BHISreferral@tanagerplace.org

If you prefer, a PDF version of this form is available for download.

Date

Referral Source (name/agency)(Required)

Client Name(Required)

First Last

Client Date of Birth(Required)

Client Age(Required)

Client Gender(Required)

Client Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Name(Required)

First Last

Relationship to Client(Required)

Parent/Guardian Phone Number(Required)

Parent/Guardian Email Address

Providing an email address, if available, helps us connect you to needed services as efficiently as possible.

Current Services & Providers(Required)

Current Tanager Place client?(Required)

Yes

Reason for Referral:(Required)

Please include information about current symptoms, behaviors, functioning and trauma. Do these occur in the home, school, community, or across all settings?

Mental Health Diagnosis (if known)

Insurance & Documentation

Please attach copy of insurance card and ABA documentation, if applicable, in upload section below. Insurance verification is required before appointment. While insurance information is not required as part of this form, providing it now will expedite the path to treatment.

Medicaid/MCO ID Number:

Name on Medicaid/MCO Card:

First Last

Insurance & Documentation Upload

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Accepted file types: jpg, pdf, png, gif, Max. file size: 256 MB.

Behavioral Health Intervention Services Referral Form

Insurance & Documentation

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