Referral Form

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REFERRAL FORM
Modern Treatment Healthcare Services

400 Main St. W. Suite 9, Valdese NC 28690
Fax Completed Form to 704-498-4390/ or email to
[email protected]
Person Making the Referral:

Prefix First Name Last Name Suffix
DATE

Month Day Year
Date
Person Needing Service:

First Name Middle Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birth date:

Month Day Year
Date
Medicaid #:
Guardian Name:

First Name Middle Name Last Name
Telephone Number

Area Code Phone Number
Email
[email protected]
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
If applicable:
Does This Person Attend a Day Program?

Yes No
Contact Number:

Area Code Phone Number
Services Requested:

Psychological Evaluation Outpatient Therapy Assessment Behavior Plan
Please Provide a Brief Explanation of Need:
Date

Month Day Year
Date
For Office Use Only:
Date Referral was received:

Month Day Year
Date
Type a question

Was Referral Accepted: No (If No, Attach Reason for Denial):
Should be Empty:

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Modern Treatment Healthcare Services