MENU Clinicare ACADEMIES CAREERS SEARCH Online Referral Form ONLINE REFERRAL FORM Please include the following information when making a referral, there are options to upload files at the bottom of the form. Relevant Legal Documents Copies of Insurance Cards (Front and Back) Most recent Psychological/Psychiatric/Diagnostic Assessment Treatment Summaries and Recommendations Out of Home Placement Agreements (MN Referrals Only) CANS Results (WI Referrals Only) Fields marked with an asterisk (*) are required. Academy/Academies: * Eau Claire Milwaukee Aurora Plains First Name * Last Name * Date Referred [cal] Sex Male Female Other Age Date of Birth [cal] Referral Source Your First Name * Your Last Name * Court Ordered * Yes No Voluntary Placement * Yes No Phone Number * Please include area code Fax Number Please include area code May we contact via email for questions? * Yes No E-mail Address Street Address Street Address Cont. City State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Currently Located at Reason For Referral Previous or current legal charges? * Yes No History of runaway behaviors * Yes No History of aggressive behaviors * Yes No Recent or significant suicide attempts * Yes No Drug and/or Alcohol abuse * Yes No Previous or current concerns of sexually inappropriate behaviors? * Yes No If yes, is youth a Registered Sex Offender? * Yes No Hallucinations/Delusions currently or within last 3 months? * Yes No IQ Current IEP * Yes No Any psychological testing completed in the last 12 months? * Yes No Reason for referral * Most recent Diagnosis * Current medications * Prescribing Physician Allergies Medical Conditions Funding County * MA# * PMAP * Secondary Insurance Private Insurance * Policy Holder Name * ID # * Policy Holder DOB * Group # * Relationship to Youth * Authorization Obtained * Yes No Authorization Number * Policy Holder Address * Policy Holder Address Cont. * Policy Holder City * Policy Holder State * State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Policy Holder Zip Code * Policy Holder Phone Number * Please include area code Relevant Legal Documents Copies of Insurance Cards(Front and Back) Most Recent Psychological/Psychiatric/Diagnostic Assessment Treatment Summaries and Recommendations Out of Home Placement Agreements (MN Referrals Only) CANS Results (WI Referrals Only) Clinicare Who We Are Academy Programs & Services Admissions News Media Get In Touch Online Referral Form TAKE THE NEXT STEP. LET CLINICARE HELP YOUR STUDENT. CONTACT ADMISSIONS TAKE OUR SURVEY Help us improve. Clinicare Clinicare Corporate Office: 11919 W Bluemound Rd Wauwatosa, WI 53226-3969 Phone: 414-545-9490 | Fax: 414-545-9491 Copyright © 2021 Clinicare Corporation. All rights reserved. Privacy Policy | Site Map