Client Referral Form
RY Services LLC | Licensed Outpatient Behavioral Health Provider — AZDHS / AHCCCS
Client Information
First Name
Last Name
Date of Birth
Gender Identity
Select...
Male
Female
Non-binary
Transgender Male
Transgender Female
Prefer not to say
Other
Preferred Language
Select...
English
Spanish
Other
Phone
Phone Belongs To
Personal
Other
Phone Owner Name
(if not personal)
Email
Address
Emergency Contact Name
Emergency Contact Phone
Insurance & Coverage
Insurance Type
Select...
AHCCCS
Private Insurance
Medicare
Self-Pay
Other
Plan Name
Monthly Premium Amount
Member ID
Group Number
Referring Party
Referring Individual / Organization
Relationship to Client
Select...
Case Manager
Therapist / Counselor
Physician / Provider
Community Outreach Worker
Family Member
Self-Referred
Other
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
Client Consent & Authorization
I consent to a clinical reassessment and outpatient treatment services at RY Services LLC.
I authorize RY Services 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 RY Services 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
Submit Referral
Clicking submit will open your email client with all information pre-filled, addressed to RY Services.
