Rely On Trusted Results

For Your Mental Health Care

Self Referral Form

Person Making Referral

Referrer Email

Phone

Name of Agency / Organization

Client First Name

Client Last Name

Date of Birth

Client Primary Email

Client Phone Number

Name of Parent / Guardian (for clients under age 18)

Relation to Client

Service(s) Requested

Individual Therapy

Family Therapy

Couples/Relationship Counseling

Psychological Testing

Psychiatry/Medication Management

RBHS

Group Therapy

School-Based

Targeted Case Management

Fit For Duty Assessment

Diagnostic Assessment

CALOCUS

Message

Insurance Provider

Policy / Medicaid Number

Service Location Preference

Privacy & HIPAA Acknowledgement:

By submitting this referral form, you are formally acknowledging that the information provided herein is, to the best of your knowledge, entirely accurate and provided with consent from the patient. You acknowledge that the information provided here is for referral purposes only, and no other Protected Health Information (PHI) is to be shared between you as the referring provider and Trusted Results Therapy Group, LLC, without proper written authorization from the patient. Trusted Results Therapy Group strictly adheres to all applicable rules and regulations governing PHI, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

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