Behavioral Health Referral Form

If you are interested in therapy or counseling services, please complete the form below. We are currently accepting members of the Inland Empire Health Plan (IEHP). If you are not a member of IEHP, we offer a sliding fee scale. Or if you have another insurance plan, please list in the form under “What is your IEHP number?”. You may be able to bill back under your plan. Thank you.

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* 1. Full Legal Name

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* 2. Preferred Name

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* 3. Pronouns

He, him, his

She, her, hers

They, them, theirs

ze, zir, zirs

Not Listed (please specify)

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* 4. Date of Birth

Date / Time

Date

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* 5. Contact Information

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 6. Sexual Orientation

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* 7. Gender Identity

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* 8. Are you currently experiencing a crisis?

Please explain

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* 9. What is your Inland Empire Health Plan (IEHP) member number?
If not, please list your insurance.