We’ve put together this online referral questionnaire to help us gather information about your client. Please, provide as much information as possible. Providers seeking information about services or the status of referrals may contact us by calling (907)333-4343 Monday through Friday, 9:00 A.M. to 5:00 P.M. (except holidays).
CHOICES, Inc. has a policy of complying with the Health Insurance Portability and Account- ability Act of 1996 (HIPAA). Our objective is always to be 100% compliant. The information you provide us with is confidential. The data you enter will be used by the CHOICES, Inc. staff for the purpose of the administration and evaluation of the referral as well as for the purpose of preparing reports that may be required by government agencies. By entering the data into our online referral tool, you consent to the processing, use, and transfer of your personal data as outlined in this agreement and statement.
We ask that you review and sign the following documents prior to completing our referral form. You will have the opportunity to add any necessary attachments at the end of the questionnaire. Referral Form.
Sincerely, CHOICES, Inc.
CHOICES, Inc. Online Referral Form
Thank you for your referral. Our agency will contact you to confirm that the referral has been received. Please discuss the nature and intent of this referral with your client. We will contact the client to schedule an appointment.'
Please, complete the fields below to your best knowledge.
- General Information
- Client Information
- Insurance Informaiton
- Clinical Information
Your agency or relation to the client:
Your phone number:
Your fax number:
City, State and ZIP
Client name (First, Middle, Last)
Preferred name (if different from above)
Date of birth
Social security number
Current home address
Which of the following best describes the housing situation for your client
Mailing address (if different from home address)
Primary phone number
Alternate contact sources (include the names, relation to the client and the contact information)
Ethnicity/Race (select all that apply)
Choose insurance from the list
Type insurance here if it isn't listed in the dropdown menu above.
Group number (if available)
Reason for referral
Primary psychiatric diagnosis
Other relevant psychiatric or medical diagnoses
Services requested (select the three most immediate)
Please, describe the reason for referral
Presenting behavioral problems
Check all that apply to your client
If not listed above, describe the behavioral problems or concersns
List current psychiatric medications (name & dose, attach list if preferred)
Danger to self (check appropriate rating)
Danger to others (check appropriate rating)
Has client been at a hospital, emergency room, crisis center or utilized mobile crisis for mental health symptoms in the past year?
Has client had any previous mental health and/or substance abuse treatment?
Other care providers
Please list all providers involved in client's care.
Client Information Sharing Consent Form
All client information is private and cannot be given to other people under Alaska State and U.S. laws and rules. The partners that can get and see the client health information must obey all these laws. They cannot give the client information to other people unless the client agrees or the law says they can give the information to other people.