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Outpatient Referral

We are happy to accept referrals and questions.

Cedar Rapids: 319-286-4545 or

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

MM slash DD slash YYYY
Client Name(Required)
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Client Address(Required)
Parent/Guardian Name (Required for clients under the age of 18)
Providing an email address, if available, helps us connect you to needed services as efficiently as possible.
Current Tanager Place client?(Required)
Date of Last Assessment

Recommended/Requested Services

Outpatient Therapy:
Psychiatric Services:
Autism Services:
Please include information about current symptoms, behaviors, functioning and trauma

Insurance & Documentation

Please attach copy of insurance card and ABA documentation, if applicable, in upload section below. Insurance verification required before appointment. Tanager Place is unable to accept Medicare insurance at this time. Private pay rates are available for insurances out of network. While insurance information is not required as part of this form, providing it now will expedite the path to treatment.
Name on Medicaid/MCO Card:
Private Insurance: Subscriber's Name
MM slash DD slash YYYY
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Accepted file types: jpg, pdf, png, gif, Max. file size: 256 MB.

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