Request A Consultation Request A ConsultationPlease complete the following information to ensure the timely and appropriate coordination of an initial referral appointment. We will contact the patient with appointment date and time. Exclusionary Conditions: Schizophrenia, IDD, AutismToday's Date* MM DD YYYY Patient InformationFirst Name*Last Name*Middle Initial*Social Security #:*Email*Date of Birth:* MM DD YYYY Sex:*MaleFemaleHome Phone:*Cell Phone:*Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County of Residence:*3rd Party CoveragePrimary Insurance Plan*Policy Number*Effective Date:* MM DD YYYY Expiration Date:* MM DD YYYY Benefits Plan*Group Number*Relationship to Patient:*SelfSpouseParentMedical ReferralPolicy Holder Name*DOB MM DD YYYY Will you be using a Secondary Insurance?*YesNoSecondary Insurance Plan*Policy Number*Effective Date:* MM DD YYYY Expiration Date:* MM DD YYYY Benefits Plan*Group Number*Relationship to Patient:*SelfSpouseParentMedical ReferralPolicy Holder Name*DOB* MM DD YYYY Interpreter Needed:*YesNoWhat Language?*Referring Source Information*Primary Care ProviderMedical Group / FacilitySelfReferral Source Name*Phone*Referral Source Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reason for Referral:*(We do not currently manage stimulants)Medication ManagementPsychotherapyHow did you hear about us?*TVAdvertisemnetEmail/NewsletterFacebookTwitterFamily/FriendInternetHealthfairWebsiteCurrent Diagnosis(es):*Both medical and psychiatric. Exclusionary conditions include: Schizophrenia, IDD, Autism.Please provide narrative for the reason of the referral and current psychiatric presentation (please be specific regarding signs/symptoms):*Send all relevant chart notes, clinical history, lab results, tests/therapy/medication history to fax # (210) 261-1837, encrypted secure email to centercare@chcsbc.org or, attach below: