Referral – Universal Therapeutic Serivces, LLC

Referring Agency:

Referring Representative Position:

Client's Legal Name (First):

Client's Legal Name (Last):

Client's Birth Date:

Client's Race:

Client's Gender:

Client's Current Address:

Client's City:

Client's State:

Client's Zip:

Client's School (if applicable):

Is client English proficient:

Yes
No
Unknown

Does client/family need translation:

Yes
No
Unknown

(This helps us to determine available benefits to clients in need

If so, what language:

Client/Parent/Guardian First Name:

Client/Parent/Guardian Last Name:

Relationship to Client:

Email:

Home Phone:

Cell Phone:

Work Phone:

Is client currently insured:

Do you currently have Medicaid/HMO Insurance:

If Yes, provide Medicaid/HMO ID number:

If No, has client had Medicaid/HMO in the past 6 months:

Also state the reason that the Medicaid/HMO insurance is no longer active:

Do you currently have Private/Commercial Insurance (BC/BS, Aetna, etc.):

If Yes, List the Carrier Name:

ID number:

Customer Service Telephone Number:

What is the best way to contact?

If No, have you had Private Insurance in the past 6 months:

Also state the reason that the private insurance is no longer active:

REASON you are requesting Universal Therapeutic Services, LLC (Describe the problem(s):

This is a secured website. All data entered is held to the utmost security. Information will not be shared with 3rd parties or disseminated without informed consent.

REFERRAL INFORMATION