Screening

Schedule a Screening

When you need additional support, Tanager Place is here to help. We serve children, teens, young adults and families as they navigate the many stressors of the world today. Our expertise and specialty trainings offer a wide range of individualized approaches. We’ll join alongside you to create solutions to enhance your wellness and well-being.

To get started on your journey with us, please complete the form below. Upon submission, our team will be in touch to discuss the services that best fit your needs. Tanager Place currently offers virtual and in-person services out of our Cedar Rapids and Coralville locations.

We are happy to answer questions. Please contact us at:

Cedar Rapids: (319) 286-4545 or therapyreferral@tanagerplace.org

Coralville: (319) 286-4520 or CoralvilleBHC@tanagerplace.org

Schedule a Screening

Date
Date Format: MM slash DD slash YYYY
Caregiver Name*
First Last
Home Phone Number*
Cell Phone Number
Email Address
Providing an email address, if available, helps us connect you to needed services as efficiently as possible.
Caregiver Address*
Street Address Address Line 2 City State ZIP Code
Relationship to Client*
Client Name*
First Last
Client Date of Birth*
Date Format: MM slash DD slash YYYY
Client Gender*
Client's Preferred Pronoun
Client Address*
Street Address Address Line 2 City State ZIP Code
Client's Current Services & Providers*
Current Tanager Place client?*
- Yes
- No
Interested Services
- Therapy (individual/group/family)
- Medication Management
Reason for Inquiry:*
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.
Medicaid Type
Medicaid ID:
Amerigroup Number:
Name on Medicaid/MCO Card:
First Last
Private Insurance: Subscriber's Name
First Last
Blue Cross Blue Shield Provider
Blue Cross Blue Shield Provider ID
Private Insurance: Subscriber's Date of Birth
Date Format: MM slash DD slash YYYY
Private Insurance: Employer Name
Private Insurance: Policy Number/Member ID
Private Insurance: Group Number/Plan Name
Insurance & Documentation Upload
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Screening

Schedule a Screening

Schedule a Screening

Insurance & Documentation