Mental Health Referral Form (External)


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:

Active Phone Number (to receive telephone calls):

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

OK to leave message:

Primary Language:

Interpreter Needed:

Type of Insurance:

Referred by (name of person and entity):

Contact Information (phone and email):

Are services mandated?

If yes, name of entity:

Referred by (if different than above):

Contact Information (phone and email):

Reason for Referral:

Additional Information:


Leave this empty:

Signature arrow


Signature Certificate
Document name: Mental Health Referral Form (External)
lock iconUnique Document ID: be094b11a2c6a2e85bad285a7f30b0c1cf89cd47
Timestamp Audit
December 16, 2020 7:18 pm PDTMental Health Referral Form (External) Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202
December 28, 2020 11:02 am PDTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129
March 18, 2021 2:55 pm PDT Document owner jdooley@c-f-d.org has handed over this document to donotreply@c-f-d.org 2021-03-18 14:55:50 - 65.157.96.202
March 18, 2021 2:55 pm PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
May 3, 2021 8:49 am PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202