RAFT Referral Form

Date of Referral

Referring Provider Information

Name

Phone Number

Email address

Fax Number

Physical Address

Client Information

Name

Date of Birth

Parent/ Guardian Name (if Applicable)

Phone Number

OK to leave voicemail?

Yes No

Home Address

Email address

Insurance Payer (If Applicable)

Insurance Member ID

How can we help?

Please provide reason for referral. Can include previous treatment, client goals, type of counseling that would be helpful such as individual or relationship, etc.

Your information will be encrypted.