Crawford Consultants & Mental Health Services, Inc.

1775 I St. NW Ste. 1150

Washington, D.C. 20006

Office (202) 587-5784 Fax (301) 341-5211 is this still accurate?

www.crawfordconsultants.org

NEW BEGINNINGS
REFERRAL APPLICATION

Referral for Services

Completed By:

Date

Referring Client Information:

Date of Birth

Age

Sex

SSN

Home Address

City

State

Zip

Contact Number(s):

Home/Mobile

Best Time to Contact:

Employed?

Place of Employment

School/University

Grade

Referred by:

Phone

Parent or Guardian Name

Emergency Contact Number

Case Worker

Case Worker Contact #

Supervisor

Supervisor Contact #

Social Worker

Social Worker Contact #

Requested Services

Clinical

Support Services

Group Services

Location

Presenting Problem

Current Diagnosis (PRP only)

Current or Past Medications

Previous Hospitalization/Treatment

If Yes, please provide details

Insurance Name

Insurance or Medicaid Number

Attachments (Court Documents, Release Forms, Consent Forms)

Authorization #

Sessions

Authorized Dates From

Authorized Dates To

Co-Pay $

Authorization #

Sessions

Authorized Dates From

Authorized Dates To

Co-Pay $

Authorization Completed By

(1) Intake Appt. Worker

Date of Intake

S/NS

(2) Intake Appt. Worker

Date of Intake

S/NS

Assigned Therapist

Date Assigned

Comments (Explain S/NS)

Crawford Consultants & Mental Health Services, Inc.

NEW BEGINNINGS REFERRAL APPLICATION

Referral for Services

Requested Services

Services

Company

NEW BEGINNINGS
REFERRAL APPLICATION