Get Referral Form - Eunoia Family Resource Center

Filling out the Referral Form for the Eunoia Family Resource Center is an important step in accessing necessary services. This guide provides clear instructions to help you complete the form online accurately and efficiently.

Follow the steps to complete the referral form with ease.

1. Click the ‘Get Form’ button to obtain the referral form and open it in your online document editor.
2. Begin by filling out the client information section. Enter the client’s name and date of birth, ensuring accuracy for identification purposes. Indicate the client’s gender by selecting the appropriate option.
3. Provide the client's address, including street address, city, state, and zip code. Also, include the phone number and specify whether it is a home, cell, work, or other type of number.
4. Indicate if it's okay to leave a message or contact about an appointment by selecting 'Yes' or 'No'. If the client is under 18, include the parent or legal guardian's name in the designated field.
5. Select the services requested by marking the appropriate options for groups or individual therapy that are applicable.
6. If applicable, complete the psychological testing section by providing the questions or concerns that need to be addressed.
7. If the referral is court-ordered, check 'Yes' and attach the court order document. Otherwise, select 'No'.
8. Fill out the referral source information, including the name, organization, address, phone number, fax number, and email address. Remember to include a signed release of information if contact is required.
9. Complete the insurance information section if available, including primary and secondary insurance companies, IDs, policy holder detail, and contact numbers.
10. Once all sections are completed, review the information for accuracy. After confirming all details are correct, you can save changes, download, or print the completed form for submission.

Complete your referral form online today to ensure access to the services you need.