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Referrals

ONLINE REFERRAL FORM
- The maximum number of form submissions has been reached. This form is currently not available.
  
  REFERRAL FOR MENTAL HEALTH SERVICES: Complete the confidential form below including required sections, then hit SUBMIT button to send your form. We will follow up with you shortly. If you have questions, call us at 713-686-9194 ext 120, 123, or 102
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Country REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Legal Guardian Please enter valid data.
  
  Legal Guardian Phone Maximum 20 characters Please enter a phone number.
  
  Referral Source Name REQUIRED Please fill out this field. Please enter valid data.
  
  Referral Source Phone REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Referral Source Email REQUIRED Please fill out this field. Please enter an email address.
  
  Primary Insurance REQUIRED Please fill out this field. Please enter valid data.
  
  Policy Number REQUIRED Please fill out this field. Please enter valid data.
  
  Name of Insured (if other than patient) Please enter valid data.
  
  Date of Birth Please enter a date.
  
  Employer Please enter valid data.
  
  Insurance Company Phone REQUIRED Please fill out this field. Please enter valid data.
  
  Group Number REQUIRED Please fill out this field. Please enter valid data.
  
  REASON FOR REFERRAL (Please check all that apply) REQUIRED
  Depressive Symptoms
  Depressive symptoms Isolation in Room Difficulty Adjusting to Dx Frequent Tearfulness Anxiety Constant Verbal Aggression Difficulty Adjusting to Facility Physical Aggression Frequent Flight From Facility Suicidal Ideation Suicidal Gesture Chemical Use / Abuse / Dependency Other Please fill out this field.
  
  If services needed sooner than 72 hours, please specify: Please enter valid data.
  
  Has the family / guardian been notified of the referral? (Indicate Yes or No) REQUIRED Please fill out this field. Please enter valid data.
  
  Completed by REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  Facility (if applicable) Please enter valid data.
  
  Submit
  
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- making a referral to Deblin health concepts
  
  Please CLICK HERE to download our interactive referral form in PDF format.
  
  Once opened, save it to your computer, complete the form, save it then email it to us by clicking on the email link below:
  
  CLICK HERE TO EMAIL THE REFERRAL FORM
  
  Or call us at 713-686-9194 ext 120, 123, or 102

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