Tanager School Based Program Referral

Getting support for your student’s mental health is easy. Complete the following form, and we will contact you and connect you to the therapist at your child’s school.

You can also download this form, complete it, and return it to your student’s school counselor.

Remember, our team is here to support you. If you have any additional questions or need further assistance, please reach out to us at 319-286-4518 or schoolbasedsups@tanagerplace.org

School Based Referral Form

Date

Name of Person Completing Form(Required)

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 for clients under the age of 18)(Required)

First Last

Relationship to Client(Required)

Parent/Guardian Phone Number(Required)

Parent/Guardian Email Address(Required)

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

Date of Last Assessment

Recommended/Requested Services

School Based Services Requested(Required)

Therapy

BHIS (Behavioral Health Intervention Services)

Mental Health Assessment

Unsure

School District & Building(Required)

Please share what district your child is in and in what building.

Psychiatric Services:

Medication Management

Psychological Testing (referral must come from health provider)

NOTE: Psychiatric Services are provided through Tanager Mental Wellbeing Clinic in Cedar Rapids, IA.

Reason for Referral:(Required)

Please include information about current symptoms, behaviors, functioning and trauma

Insurance & Documentation

Please provide the following information about your child's insurance coverage. This is not required at this time, however it is required prior to the start of services. Providing it now will allow us to most efficiently meet your child's needs.

Medicaid Type

Medicaid ID Number:

Amerigroup Number:

Name on Medicaid/MCO Card:

First Last

Blue Cross Blue Shield Provider:

Blue Cross Blue Shield Provider ID:

Private Insurance: Subscriber's Name

First Last

Private Insurance: Subscriber's Date of Birth

Private Insurance: Policy Number/Member ID

Private Insurance: Group Number/Plan Name

Private Insurance: Employer Name

Insurance & Documentation Upload

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

Tanager School Based Program Referral

School Based Referral Form

Recommended/Requested Services

Insurance & Documentation

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