BHC Online Child Referral Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CHILD MUST BE AT LEAST 7
DOB:
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Race:
Ethnicity:
Religion:
Email:
*
Primary Doctor:
Guardian's Name:
First Name
Last Name
Relationship To Child:
Does parent have custody of child? If not, who does?
What school does the child attend?
Grade:
Does the parent/guardian want in-school services?
Telehealth:
Insurance Carrier #1:
*
ID#:
*
Insurance Carrier #2:
ID#:
IF CLIENT IS NOT THE SUBSCRIBER, PLEASE COMPLETE BELOW:
Subcriber Name:
DOB:
-
Month
-
Day
Year
Date
Relationship to Client:
Who is Referring Client:
Reason For Referral:
Current Medications:
Therapist Preference:
Male
Female
First Available
Place of Service Preference:
Office
Telehealth
Other
Any Special Request:
Submit
Should be Empty: