Patient Referrals

Follow these steps:

1. Retrieve the Patient Referral Form.
2. Please filled in the patient’s required details for referral.
3. Send the filled-out form via fax to any of our ABHC locations listed on the form or available here.

4. Complete the online referral form below, and we’ll take care of the rest—no printing or faxing needed!

Patient Referrals Form

Date
Please confirm today's date:

Today's Date:

Referral Details
Please provide your details for the referral:

Referred by:

Please fax this referral to:

Diagnosis/Reason for referral:

Select which apply:

Mental Health Alcohol and Drug Abuse

We will call the client, schedule an appointment, and fax information back to you. (Please provide the information below)

Telephone Number:

Fax Number:

Insurance Type
Please provide the patient health insurance information for the referral:

Patient Details
Please share your patient details for the referral:

Full Name:

Male/Female:

Parent/Guardian Name:

Relationship to Patient:

Street Address:

City:

County:

State:

Zip:

Home Phone Number:

Cell Phone Number:

Work Number:

Emergency Contact Telephone Number:

Marital Status:

Date of Birth:

Age:

Start your journey to transformative health today. Simply complete the form, and allow Access Behavioral Health to lead you toward holistic well-being.

Referrals

Patient Referrals

Patient Referrals Form

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