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Filling Out Form

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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.

Intake Referral Form

Insurance Type
Blue Cross Blue Shield/Healthy Blue
Wellcare
Regular Medicaid
Gender
Male
Female
Date of Birth
Month
Day
Year
Court Mandated?
Yes
No
Has the child had other services (e.g. Individual-CSI, Individual and /or Family Counseling)?
Yes
No
Not Sure
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
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
Has Psychological/Psychiatric Evaluation been completed? If yes, please upload.
Yes
No
Service(s) Requested (Please Check)
Current Symptoms
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