Referral Source Information

Your Name (Referring Person) *

Organization / Agency *

Your Role / Title

Your Phone Number *

Your Email *

Client Information

Client Full Name *

Client Date of Birth *

Client Phone Number

Client Gender
-- Select --MaleFemaleNon-binaryPrefer not to say

Client Preferred Language
EnglishSpanishOther

Residential & Insurance Information

Current BHRF / Facility Name *

BHRF Address

BHRF Contact Person

BHRF Contact Phone

Insurance / AHCCCS ID *

Health Plan
-- Select --AHCCCS - Mercy CareAHCCCS - United HealthcareAHCCCS - Banner UniversityAHCCCS - Arizona Complete HealthAHCCCS - Care1stMedicarePrivate InsuranceSelf-PayOther

Clinical Information

Primary Behavioral Health Diagnosis

Secondary Diagnosis (if applicable)

Current Medications

Services Requested *
Behavioral Health AssessmentIndividual CounselingGroup CounselingCase ManagementCrisis InterventionPsychoeducation/Skills TrainingCare CoordinationDischarge PlanningMedication Monitoring

Brief Description of Presenting Concerns *

Safety & Risk Information

Are there any current safety or risk concerns?
No current concernsHistory of self-harmHistory of suicidal ideationHistory of aggressionSubstance use concernsElopement riskOther (describe below)

Additional Safety Notes

Additional Information

Any additional information or special considerations?

How did you hear about EBRU Care?
-- Select --BHRF referralProvider referralCommunity agencyWebsiteWord of mouthOther