Patient Referral The Village is pleased to be the behavioral health partner for Candlewood Valley Pediatrics. "*" indicates required fields This field is hidden when viewing the formPractice Name*Doctor’s name*This field is hidden when viewing the formPractice address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your name* First Last Your email* Your phone*Patient informationUrgent/Emergency? Check if this referral is considered urgent/emergency and provide a brief reason why. Provide more informationPatient Name* First Last Patient Date of Birth* Month Day Year Guardian’s Name #1* First Last Guardian’s Name #2 First Last Patient/Parent Tel #1*Patient/Parent Tel #2Patient/Parent Email Address* Behavioral Concerns* Anxiety Depression Behavior management Suicidal thoughts/self harm Social isolation Anger issues Aggressive behavior Other Behavioral Concerns: OtherInsurance informationWe do not turn anyone away if they are not covered by insurance. If insurance information is available, please send a copy of the card along with this referral or complete the box below.Copy of insurance cardAccepted file types: pdf, jpg, png, Max. file size: 512 MB.Insurance company name*Insurance company phone numberInsurance ID*Policyholder name*Policyholder Date of Birth Month Day Year Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code ConsentConsent* *Required: by checking this box, I certify that I have obtained verbal consent from the parent/guardian to make this referral to The Village for Families and Children. Upload additional documents Drop files here or Select files Accepted file types: jpg, png, pdf, xdoc, doc, Max. file size: 5 MB, Max. files: 5. Please tell us any other information you feel is important.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
