New Patient Referral Form | Indiana Health Group

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Referral Source

Are you referring FROM a physicians office or other facility?

Yes

Physician/Facility Referral:

Aware Recovery Care

Emberwood

Priority Physicians

St. Vincent Stress Center

Other: Behavioral Healthcare Provider

Other: Physician Office

Other: Primary Care Provider

Other: Inpatient Facility

How did you hear about our office?(Required)

Family Member

Insurance Company

JCC - Jewish Community Center

Psychology Today

Print Publication/Promotional Video

Online Search

Which provider(s) would you prefer to schedule with?(Required)

Katie Clendenen, LMHC

Jenna Doyle, LMHC

Marabeth Holland, LMHC

Elizabeth Irick, LMHC

Maryann Lake, LCSW

Francia Siler, LCSW

Other

Other Provider Prefer to Schedule With:(Required)

Please let us know if there a day or time that works best for your patient/client?

Which provider would you prefer to schedule with?(Required)

Darrin Mangiacarne, DO

Other

Other Provider Prefer to Schedule With:(Required)

Name of physician, office, or other professional making referral:(Required)

Contact Name (on behalf of physician, office, or other professional) - if different from above.

Name of person making the referral:(Required)

Contact Phone:(Required)

Contact Fax:

Contact Email:

Reason for referral, symptoms, etc.:(Required)

Patient Demographic Information

Patient's Name:(Required)

First Last

Patient prefers to go by (nickname):

Patient's Date of Birth:(Required)

Is the patient a minor?(Required)

Yes

Parent/Guardian if patient is a minor:

First Last

Parent/Guardian Phone:

Parent/Guardian Email:

Legal Sex:(Required)

Male

Female

Other

Gender Identity:

Male

Female

Trans-Male

Trans-Female

Non-Binary

Other

Sexual Orientation:

Heterosexual

Bisexual

Gay

Lesbian

N/A

Patient's Address:(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone:(Required)

Secondary Phone:

Email Address:(Required)

Emergency Contact Information

Emergency Contact's Name:

First Last

Relationship to Patient:

Emergency Contact's Primary Phone:

Emergency Contact's Secondary Phone:

Emergency Contact's Email Address:

Insurance/Contracted Services

Services will be covered under the following contract:

Emberwood

AWARE Recovery

Does the patient your are referring have insurance they would like to utilize?

Yes

Does the patient your are referring have insurance they would like to utilize?

Anthem/Blue Cross Blue Shield

Cigna

ComPsych

Midwest Behavioral Health/New Avenues

Sagamore/IHG

United Healthcare/United Behavioral/ UMR

Private Pay (IHG and/or the provider I will be seeing does not participate with my insurance plan)

Mental health benefits may be administered by a plan other than your primary healthcare benefits. We highly encourage each patient to familiarize themselves with their mental health benefits and confirm the participation status for the provider they wish to see. Patients are ultimately responsible for charges incurred as a result of services rendered with an out-of-network provider.

Contract Billing

Services will be covered by:

AWARE Recovery

Emberwood Center

Services

I am referring the patient for:(Required)

Medication Management

Therapy

Both

Please choose the MEDICATION MANAGEMENT provider that you would like to refer to:

Please choose the THERAPIST that you would like to refer to:

Contact Information

Contact instructions(Required)

Patient has been instructed to complete New Patient Pre-Registration Form online (recommended)

Please contact the patient / parent or guardian to schedule an appointment

The patient has been provided with the contact information for Indiana Health Group

Best time to call:

7:00am - 9:00am

9:00am - 11:00am

11:00am - 1:00pm

1:00pm - 3:00pm

3:00pm - 4:00pm