1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Mental Health Referral Form (External)

Legal Name:    Date of birth:

Preferred Name (if different):

Referral to:

Perinatal ProgramMental Health ProgramOther (specify below)

Active Phone Number (to receive telephone calls):

Phone has been verified as active (by person making referral): Yes

OK to leave message: YesNo

Primary Language: EnglishSpanishOther (specify below)

Interpreter Needed: YesNo

Type of Insurance:  Oregon Health Plan Medicare Commercial (specify below) None

Referred by (name of person and entity):

Contact Information (phone and email):

Are services mandated? YesNo

If yes, name of entity:

Referred by (if different than above):

Contact Information (phone and email):

Reason for Referral:

Additional Information: