Client Referral Form

DBOTC LLC

Licensed Outpatient Behavioral Health Provider — AZDHS / AHCCCS

Client Information

First Name Last Name Date of Birth Gender Identity Preferred Language Phone Phone Belongs To

Personal Other

Phone Owner Name Email Address Emergency Contact Name Emergency Contact Phone

Insurance & Coverage

Insurance Type Plan Name Monthly Premium Amount Member ID Group Number

Referring Party

Referring Individual / Organization Relationship to Client Phone Email

Presenting Concerns & Clinical Need

Primary Reason for Referral Areas of Concern (check all that apply)

Substance Use Mental Health Co-Occurring Disorders Trauma Crisis Stabilization Other

Additional Clinical Notes

Building Solid Foundations501(c)(3) Treatment-Based Housing Community Resource

Do you need help with housing or paying your lease?

Yes No

I consent to a clinical reassessment and outpatient treatment services at DBOTC LLC.

I authorize DBOTC to verify and bill my insurance or AHCCCS plan for services rendered.

I understand this referral does not guarantee admission and that a formal intake and assessment will be completed prior to enrollment.

Release of Information: I authorize DBOTC to communicate with the referring party named above regarding my treatment status and progress.

Client Signature (type full legal name) Date Guardian Signature (if applicable) Guardian Relationship

Clicking submit will open your email client with all information pre-filled, addressed to DBOTC.

DBOTC LLC | Provider ID: 093020 | NPI: 1912508342

1616 E. Main St., Suite D, Mesa, AZ 85203 | john@dbotccommercial.com