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Summit Psychological Associates, Inc. Return to: [email protected]
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