NEHS – Website – Intake Team Referral Lander

Please complete the form below with the information about yourself and details about the client/patient you are referring
Referring Organization Name
Referring Organization Contact Person
Referring Organization Phone
Please enter a valid phone number.Format: (000) 000-0000.
Referring Organization Email
example@example.com
First time referring?
Client Information
Is this request urgent?
If urgent, please indicate criteria that makes the referral urgent
Client/Patient Name

First NameLast Name
If client is under 18, guardian name

First NameLast Name
Client/Patient Date of Birth

MonthDayYear
Date
Client/Patient Email
example@example.com
Client/Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Language
Preferred Clinic
Insurance Plan
Insurance Plan ID #
Secondary Insurance (if applicable)
Secondary Insurance Plan ID #
Reason for referral (symptoms and treatment needs)
Requested Services
Preferences
Preferred time of appointment
PCP Name
Hospital discharge?
Current medications
Medical Records

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Client Information