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FORMS/RECORDS
281-706-6848
Referral/Verification of Benefits Form
Referral/Verification of Benefits Form
Today's Date
Client Full Name
Client Date of Birth
Client or Parent/Guardian Phone Number
Best Time to Contact
If completing referral for a minor under 18 years of age, who is the Primary Caregiver/Guardian.
Parent/Guardian/LAR Name
write None or NA if client is an adult
If guardian is someone other than biological parent, written evidence of custody/ conservatorship will be required at intake.
Referral Source
write Self if filling out for yourself
Referral source point of contact phone number
Client Insurance Provider
Insurance Number (optional)
Areas of Concern Select All that apply
Sadness or Depressed mood
Panic attacks
Feeling numb
Irritable mood
Worries excessively
Anxious
Hyperactive
Flashbacks
Nightmares
Difficulty concentrating
Fearful/Easily startled
Anger issues
Suicidal/Self-harm thoughts
Hearing voices Self-harming behavior
Thoughts of harming others
Feeling hopeless or helpless
Low self-esteem
Diminished interest in activities
Eating or Appetite
Problems at work
Problems at school
Difficulty sleeping
Substance use or addiction
Phobias
Housing issues
Abusive relationships
When did these problems start and how often do they occur?
How are these problems affecting you?
Has client been previously diagnosed or had treatment?
Please list known diagnoses and previous treatment clinics/doctors. If none, write None
Is client referred currently receiving treatment from a provider or doctor?
Please enter the name and phone number of current provider or write None if none
Thank you for your interest in our Services. We will receive your referral once submitted. We look forward to speaking with you soon.
If you need immediate assistance please text us at 281-706-6848. If you are experiencing a crisis or emergency please call 911
New Client Inquiry and Referral Form will be submitted to Alpha Recovery, LLC
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