Behavioral Health Intervention Services Referral Form

We are happy to accept referrals and questions. Please contact us at:

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

Date
MM slash DD slash YYYY
Referral Source (name/agency)*
Client Name*
First Last
Client Date of Birth*
MM slash DD slash YYYY
Client Age*
Client Gender*
Client Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian Name*
First Last
Relationship to Client*
Parent/Guardian Phone Number*
Parent/Guardian Email Address
Providing an email address, if available, helps us connect you to needed services as efficiently as possible.
Current Services & Providers*
Current Tanager Place client?*
- Yes
- No
Reason for Referral:*
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
Drop files here or

Accepted file types: jpg, pdf, png, gif, Max. file size: 100 MB.

Insurance & Documentation