REFERRAL FORM - Summit Psychological · Summit Psychological Associates, Inc. Return to:...

Summit Psychological Associates, Inc. Return to: referral@summit-psychological.com

Intake Phone: 234.718.2331Intake Fax: 234.571.9107

☐ North Akron557 N Main StAkron, OH 44310Ph: 330.787.0031Fx: 234.900.6016

DOB:SSN:

E-mail:

Phone:

Client's Name: Gender:Street Address: City, State, Zip: Main Phone: Other Phone: Referring Organization: Contact Name:

Psychological Evaluation

Treatment Assessment

SMART Program/Vivitrol MAT

Payment Type: Client's Medicaid/Medicare #

REFERRAL FORM

Choose the Service Location

Client's Insurance

Treatment Request Choose All That Apply

This service includes a clinical interview, review and incorporation of pertinent records and administration of psychological testing as needed, and a formal written report.

This service includes a standard intake with a clinician that is followed by development of a treatment plan and initiation of treatment.

This service provides comprehensive mental health and substance abuse services for individuals suffering with opiate or alcohol addiction.

Reason for Referral - Please explain and choose a service

Thinking for a Change

New Foundation Drug and Alcohol 26 Week Program

New Foundation Drug and Alcohol 12 Week Program

Drug and Alcohol 6 Week Education Program (Sober Success - Portage County Jail Only)

Pride in Parenting 10 Week Program

Individual Mental Health Counseling (based on assessment or evaluation)

New Directions - 12 week trauma based program for prostitution or sex trafficking victims

Freespace Program

HOPE Program

Other

Adult Sex Offender Treatment Program

Juvenile Sex Offender Treatment Program

Conflict Solutions Anger Management - 26 Week Program (no assessment or eval needed)

Conflict Solutions Anger Management - 10 Week Program (no assessment or eval needed)

TOD Program (Family Violence Court Referrals Only)

52 Week Battered Intervention Program (Summit County Court of Common Pleas-Domestic Violence Docket Only)

Anger Management Batterers Intervention Program (Only referrals from Summit County Judge Gallagher's Court)

Restoration Treatment

DATE:

Insurance Provider

Member ID

Client is Self-Pay

Fax:

☐ Akron37 N BroadwayAkron, OH 44308Ph: 330.535.8181Fx: 330.535.9303

RavennaChestnut Medical Arts Bldg6693 N. Chestnut St., #235 Ravenna, OH 44266 Ph: 330.296.3700Fx: 330.298.1460

Female Male Transgender

Referring Organization will be BilledATP Funding

☐ Canton832 McKinley Ave NWCanton, OH 44703Ph: 330.493.2554Fx: 330.493.9520

☐ FremontBrady Building Suite 301219 S. Front St.Fremont, OH 43420Ph: 567.432.5070Fx: 567.314.0010

Tiffin65 St. Francis Ave.Tiffin, OH 44883Ph: 567.220.7018 x 4212