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REFERRAL AND RELEASE FORM BEHAVIORAL HEALTH SERVICES

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REFERRAL AND RELEASE FORM BEHAVIORAL HEALTH SERVICES
For children and youth, age 20 and under, who may be in need of behavioral health services. Please notify the
referring provider if the family has not called for an appointment within 4 weeks of this referral. Please see
“Instructions for Pediatric Healthcare Provider Patient Referral for Behavioral Health Services” for Behavioral
Health Organization contact information.
Child’s First Name: _______________________ Child’s Last Name: _______________________
DOB: ___________ Male Female Medicaid ID #__________________
Other Insurance: ________________________________
(Foster) Parent or Guardian Name: __________________________________________________
Address: _______________________________________________________________________
City: __________________________ State: ______ Zip: _________ County: _________________
Primary Phone #: _______________________ Secondary Phone #: ________________________
Primary Language Spoken: English Spanish Other ___________________________
If foster parent, how long has this child been at this residence? _______________________
Assigned DHS Case Worker (if applicable): ______________________________________
County: ______________________________ Phone #____________________________
Referring Medical Provider Practice/Clinic Name: _______________________________________
Referring Medical Provider Address: _________________________________________________
City: _______________________ Phone #: ___________________Fax #: ___________________
Date of last physical/well-child check-up: ______________________________________________
Has some type of social emotional, developmental, or behavioral screening been completed for this
child? Yes No (If yes, please attach a copy to this referral)
What concerns caused this referral?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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Medical Issues/Concerns: _________________________________________________________
______________________________________________________________________________
Medications: ____________________________________________________________________
RELEASE
I authorize ___________________________________ (medical provider referral source) to release
the following information (check all that apply):
Referral Information
Social Emotional/Developmental Evaluations and/or Developmental Screening Results
Admissions Summary
Discharge Summary
Other: _________________________________________________________________
This authorization expires on ____________________ (expiration date not to exceed 1 year from
date of signature).
Signed: ______________________________________________________
Must be signed by parent, guardian or case worker
Date: __________________________________
PLEASE ATTACH YOUR OFFICE HIPAA RELEASE TO THIS FORM
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REFERRAL AND RELEASE FORM BEHAVIORAL HEALTH SERVICES

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Completed 9 November 2021

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