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Initial Submission

Colonial IU 20 Resolve Outpatient Referral

Demographics Section

School Year of this Request:*

Referral Date*

Phone Number of Self Referrer

Type of Referrer*

Email Address of Person Completing this form*

Tentative Discharge Date*

Name of Person Referring*

Client's Residency Status*

Contact Telephone Number*

Client's Legal Name*

First Name

Last Name

Gender*

Client's Date of Birth*

Client's Age

Client's Email Address

District/Agency & Job Title*

Please enter Other Agency

District Currently Attending*

LEA/District/Charter Requesting Services*

Please choose the appropriate District

Current Allentown Building Client Attends*

Current Bangor Building Client Attends*

Current Bethlehem Building Client Attends*

Current East Stroudsburg Building Client Attends*

Current Easton Building Client Attends*

Current Del Val Building Client Attends*

Current Nazareth Building Client Attends*

Current Northampton Building Client Attends*

Current Pen Argyl Building Client Attends*

Current Pleasant Valley Building Client Attends*

Current Pocono Mountain Building Client Attends*

Current Stroudsburg Building Client Attends*

Current Saucon Valley Building Client Attends*

Current Wilson Building Client Attends*

Other Agency Building Client Attends*

Guidance Counselor's Name

First Name

Last Name

Guidance Counselor's Email

Client's Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Client's Grade*

Kindergarten = 0 / Pre-K = -1

Client's Ethnicity*

Client's Primary Language is English*

Parent/Guardian Primary Language is English*

Is an Interpreter Needed?

Who is in need of the interpreter

Client Parent Both

Client's Primary Language

Parent/Guardian Primary Language

Primary Parent / Guardian Name*

First Name

Last Name

Primary Parent / Guardian Phone*

(555) 555-5555

Primary Parent / Guardian Secondary Phone

(555) 555-5555

Primary Parent / Guardian Email*

me@internet.com

Primary Parent / Guardian Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Would you like to add a Second Parent/Guardian?

Second Parent / Guardian Name *

First Name

Last Name

Second Parent / Guardian Phone*

(555) 555-5555

Second Parent / Guardian Address *

Address Line 1

Address Line 2

City

State

ZIP Code

Foster Home Address *

Address Line 1

Address Line 2

City

State

ZIP Code

Client Educational Plan*

Client has Individual Educational Plan (IEP) Client has Chapter 15 (504) Plan Client is Regular Education Unknown

Insurance Information

Client's Insurance Coverage*

Client's Insurance Information*

Private Insurance Provider*

Subscriber Name*

Subscriber Date of Birth*

Private Identification (ID) #*

Type of Plan

MA Number

State Id Number

Private Group #

Private Insurance Phone Number(s) Listed on Back of Insurance Card

Does client have Second Private Insurance

Second Type of Plan

Second Subscriber Name*

Second Group #

Second Insurance Phone Number(s) Listed on Back of Insurance Card

Second Subscriber Date of Birth

Second Insurance Provider*

Second Identification (ID) #

Upload Insurance Card (Front and Back)

No File Chosen

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Medical Billing Review

Medical Billing

Date Contacted/Verified*

Contact/Verification Made*

Contact Notes*

Type of License*

Confirmed 1st Attempt

Schedule Appointment*

Second Contact Attempt

Second Date Contacted/Verified*

Second Contact/Verification Made

Second Contact Made notes*

Type of License

Confirmed 2nd Attempt

Schedule Appointment Second Contact*

Third Contact Attempt

Third Date Contacted/Verified*

Third Contact/Verification Made*

Third Contact Made Notes*

Type of License

Confirmed 3rd Attempt

Schedule Appointment Third Contact*

3rd Attempt Response

Did Client Respond to the 3rd attempt*

3rd Response Notes*

Is an appointment to be scheduled*

Notification

Notification Section

Notification Group

Appointment to be scheduled

Intake Section I

Was there contact with the family

Was this referral accepted

Is there an intake date scheduled*

Date of Intake*

Intake Comments

included in emails

Referral Notes

Internal Use only

Is there are therapist assigned

Name of assigned therapist

First Name

Last Name

Date and time of Evaluation

Is this referral now closed*

Reason why this referral is now closed*

Intake Section II

Was there contact with the family. Attempt 2

Was this referral accepted. Attempt 2

Is there an intake date scheduled. Attempt 2*

Date of Intake. Attempt 2*

Intake Comments. Attempt 2

included in emails

Referral Notes. Attempt 2

Internal Use only

Is there are therapist assigned. Attempt 2

Name of assigned therapist. Attempt 2

First Name

Last Name

Date and time of Evaluation. Attempt 2

Is this referral now closed. Attempt 2*

Reason why this referral is now closed. Attempt 2*

Intake Section III

Was there contact with the family. Attempt 3

Was this referral accepted. Attempt 3

Is there an intake date scheduled. Attempt 3*

Date of Intake. Attempt 3*

Intake Comments. Attempt 3

included in emails

Referral Notes. Attempt 3

Internal Use only

Is there are therapist assigned. Attempt 3

Name of assigned therapist. Attempt 3

First Name

Last Name

Date and time of Evaluation. Attempt 3

Reason why this referral is now closed. Attempt 3

Is this referral now closed. Attempt 3

Initial Submission

Colonial IU 20 Resolve Outpatient Referral

Demographics Section

Insurance Information

Reason for Referral

Medical Billing Review

Second Contact Attempt

Third Contact Attempt

3rd Attempt Response

Notification

Intake Section I

Intake Section II

Intake Section III