CIA - Community Intervention Associates of Yuma

Referral For Behavioral Health Services
Community Intervention Associates
3802 W. 16^th Street Yuma, AZ 85364|
Office (928) 376-0026 FAX (928) 782-2298

I. INFORMATION ON PERSON BEING REFERRED FOR SERVICES * denotes required field

Name:*

Gender:
Male Female

Age:

Address:

Date of Birth:*

City State Zip:

Contact Phone:*
- -

Name of Parent/Legal Guardian
( * if person is under age 18)

Parent/Guradian's Phone
( * if person is under age 18)
- -

Person Making Referral/ Contact Phone
/ - -

Is Person/Parent aware of referral?
Y N

Is person court ordered?
Y N

Name of Person's Primary Care Physician or M.D. Psychiatrist

Payment Source
AHCCCs I.D. #
Insurance Medicare
Contract Self-Pay

Special Needs:

Mobility Assistance	Visual Impairment	Hearing Impairment
Cognitive Impairment	Services Required in Spanish

Is person currently taking any medication to treat a behavioral health condition:
N Y - Date Rx will expire:

II. Services Requested

Risk Factors

Intake and Psychosocial Assessment
Individual or Family Counseling
Substance Abuse Treatment
Psychiatric Health Services
Child & Adolescent Services
Parenting Classes
In-home Family Support
Other:

History of DTS or DTO behaviors
Pregnant Woman
Intravenous Drug Use (IDU)
Recently discharged from an inpatient setting
Young adult in transition
Other:

III. Reason for Referral *