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Pediatric Integrated Health Referral Form
Home
Pediatric Integrated Health Referral Form
We are happy to accept referrals and questions.
Please contact us at
(319) 286-4531.
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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):
Diagnosed By:
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.
Managed Care Organization
Amerigroup
Iowa Total Care
Iowa Medicaid Enterprise (IME)
Medicaid/MCO ID Number:
Name on Medicaid/MCO Card:
First
Last
Insurance & Documentation Upload
Drop files here or
Select files
Accepted file types: jpg, pdf, png, gif, Max. file size: 100 MB.
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