School Based Therapy

School Based Therapy

Referral Form
Please Note! This referral is not considered received by MAHEC until you receive a confirmation number after clicking the submit button.
Requested Service
Referring Source
Who is submitting this referral?*
If you are referring yourself or a family member, please select "Self/Family Member"
School*
Referring Agency*
Referring Agency Provider or Contact*
Referring Agency Phone
Please enter a valid phone number.
Referring Agency Fax
Please enter a valid fax number.
Referring Agency Email
example@example.com
Send a confirmation number to this email?

Yes
Patient Demographics
First Name*
Legal First Name
Last Name*
Legal Last Name
Middle Initial
First Name Patient Goes By
If different than Legal First Name
Date of Birth*

MonthDayYear
Data
Assigned Sex at Birth*
Pronouns
Race*
Ethnicity*
Primary Language*
Language Spoken at Home*
Insurance Information
Insurance
Please type in any patient insurance information. Please type "NA" if none or unknown
Contact Information
Today

MonthDayYear
Date
Patient Age
Please provide the contact information of the student as they are 18+ yrs old.
Please provide legal guardian name and contact information.
Guardian Name*
Phone Number*
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.
Email
example@example.com
Send a confirmation number to this email?

Yes
Patient Address
Street Address*
Apt, suite, unit or floor #
City*
State*
Zip Code*
Input as 5 digits (e.g. 12345)
Referral Details
School*
School Field Value
Current Grade
Reason*
Please briefly describe the primary reason(s) that the patient is requesting services.
Attention: Please note that if the patient becomes a MAHEC client, this reason will be included in the referral that is saved to the patient’s chart.
Please attach additional patient documentation to this request form or fax to (828) 333-5465

Up to 10 files may be uploaded
Cancelof
Should be Empty:

School Based Therapy

Referring Source

Patient Demographics

Insurance Information

Contact Information

Patient Address

Referral Details