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Filling Out Form

submit a referral today

Your Referral Can Change a Life

There are times in life when we all need a little help. At Redi Behavioral Health, we’re here to provide the care and support that help individuals and families navigate life’s challenges. If you know someone who could benefit from our services, please take a moment to complete the form below so we can connect them with the assistance they need.

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June, and Juneteenth, are times to honor the

resilience, rich history, and profound contributions of African Americans

Intake Referral Form

MEMBER INFORMATION

Gender
Male
Female
Other
Date of Birth
Month
Day
Year
Insurance Provider
Healthy Blue
Partners
Other

PARENT/GUARDIAN INFORMATION

REFERRAL INFORMATION

SERVICES REQUESTED

Has the child had other services (e.g. Individual-CSI, Individual and /or Family Counseling)?
Yes
No
Unsure
Does the child have a known Serious Emotional Disturbance and/ or Substance Abuse issue/diagnosis?
Yes
No
Unsure
Are child and/or family issues in need of intensive, coordinated clinical and supportive intervention?
Yes
No
Unsure
Is the child at immediate risk of out of home placement or is currently in out of home placement and re-unification is imminent?
Yes
No
Unsure
Has Psychological/Psychiatric Evaluation been completed? If yes, please upload.
Yes
No
Unsure
Service(s) Requested (Please Check)
Problems or Concerns

SERVICING DETAILS

TRANSPORTATION DETAILS

Requested Origin Time
Time
HoursMinutes
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