Referral Referral Form If you or the person you are referring is experiencing a crisis, please call 1-877-277-2226! This referral form is for non-crisis situations. Step 1 of 2 50% Step One: Referred Individual InformationName of Referred* Name of Parent or Legal Guardian (if applicable) Insurance Information This individual uses Medicaid This individual uses Medicare This individual uses Other Insurance Insurance Unknown This individual does not have Insurance Date of Birth* Gender* Ethnicity* Race* Address* City* County* State* Zip* Home Phone Work Phone Cell Phone* Email Step Two: Referrer Information Self Referral Referrer Name Relationship to Individual Date of Referral Phone Email Office/County Individual Referred To*GraysonFanninCookeIndividual is a(n)*AdultAdult and VeteranChild or AdolescentReferring Organization Reason for Referral*If applicable, is the parent/guardian aware that a referral has been made* Yes No N/A I give permission to allow information to be left on voicemails or email Any Additional Information
