Make An Appointment

Referral Info

Please select the date of the referral.
mm/dd/yyyy
This field is required.
Please select the scheduled date for the DA visit.
mm/dd/yyyy
This field is required.
Please select the scheduled time for the DA visit.
This field is required.
Please enter the name of the referral contact.
This field is required.
Please describe the relationship to the client.
This field is required.
Please enter a contact phone number.
This field is required.
Optional: Please enter a fax number if available.
This field is required.
Please enter the name of the referral agency.
This field is required.
Please provide the reasons for the referral.
This field is required.
Please specify any language needs.
This field is required.

Client Information

Please enter the client's full name.
This field is required.
Please select the client's date of birth.
mm/dd/yyyy
This field is required.
Please enter the client's address.
This field is required.
Please enter the city of residence.
This field is required.
State - Please select
Please select the client's state of residence.
This field is required.
Please enter the ZIP code.
This field is required.
Please provide the client's phone number.
This field is required.
Gender
Please select the client's gender.
Please enter the insurance provider's name.
This field is required.
Please enter the insurance ID number.
This field is required.
Please enter the MA/PMI information if applicable.
This field is required.

Privider Information

Is this referral for a primary care client?
This field is required.
Please provide the name of the primary care doctor.
This field is required.
Please enter the phone number of the primary care doctor.
This field is required.
Optional: Please enter the fax number of the primary care doctor.
This field is required.
Please provide the name of the case manager.
This field is required.
Please enter the name of the agency.
This field is required.
Please enter the case manager's phone number.
This field is required.
Optional: Please enter the fax number of the case manager.
This field is required.
Please provide the name of the psychiatrist.
This field is required.
Please provide the name of the psychiatrist's clinic.
This field is required.
Please enter the psychiatrist's phone number.
This field is required.
Optional: Please enter the fax number of the psychiatrist.
This field is required.
Previously Received ARMHS
Has the client previously received ARMHS?
If yes, please enter the agency where ARMHS was received.
This field is required.