Date

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)

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(Required)

Current Tanager Place client?(Required)

Yes

Date of Last Assessment

Recommended/Requested Services

Outpatient Therapy:

Cedar Rapids Clinic

Coralville Clinic

School Based (provide school name)

School Name, if applicable:

Psychiatric Services:

Medication Management

Psychological Testing (referral must come from health provider)

Autism Services:

Social Skills Group

Testing/Assessment

ABA Services (include documentation showing medical diagnosis below)

Reason for Referral:(Required)

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 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

Drop files here or

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

Outpatient Referral

Recommended/Requested Services

Insurance & Documentation

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