Is your adolescent or teen struggling with their mental health? We offer assessments for treatment and medication within 48 hours.
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Beyond Healthcare
Mental Health Therapy Center for Teens in Toledo Ohio
CALL TODAY 833.698.0453
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Blog
Home
About
Work With Us
Mental Health Services
Mental Health Assessment & Diagnosis
Adverse Childhood Experience Questionnaire for Adults
Partial Hospitalization Program
Intensive Outpatient Program
Mental Health Day Treatment & Afterschool programs
Medication Management
Virtual Therapy
Individual & Group Therapy
What We Treat
What to Expect
Family Sessions
Contact Us
Authorization for Release of Information
Mental Health Services Referral Form
Insurances We Accept
Blog
Mental Health Services Referral Form
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Mental Health Services Referral Form
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Referral Information
Child/Youth's Name
First
Last
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Other
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Legal Guardian's Name
First
Last
Phone
Can a message be left?
Yes
No
Reason for Referral
Provider Information
Name
First
Last
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
Date of Referral
MM slash DD slash YYYY
Mental Health Diagnosis
Signature
Insurance Provider
Medicaid
Commercial (Out of Network Only)
If Commercial, which plan?
Commercial/Medicaid Number
Beyond Healthcare Intake Team to Complete
Intake Completed
MM slash DD slash YYYY
Unable to contact Guardian
Guardian declined services
Staff Processing Referral
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