Maryhurst Renewal Referral Form

Welcome!

We're so excited to begin our partnership with you! To ensure we have the information we need to best serve you, please take a few moments to fill out the form below. Once submitted, someone from our staff will make contact and schedule an intake for services.

If you have any questions, please feel free to contact us any time at (502)438-9639. Thank you!

I am requesting an appointment for:

myself or a family member a patient, student, or client of mine

Contact Information

Please enter the full name of the individual you're requesting services for *

If you're self-referring, this will be your name. If you're filling this form on behalf of someone else, list their name (you will give your name in a future question)

Please provide the address of the individual you're requesting services for (If you're self-referring or referring someone in your household, this will be your address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Your Name (or name of the guardian of the individual you're requesting an appointment for)

First Last

Contact Phone Number

123-456-7890

Contact Email Address

example@provider.com

How would you prefer we contact you?

Phone Call Email Text Message

Please note your appointment location preference:

Please fill in the blanks with any identity preferences you have for your therapist (we will do our best to pair you with a Renewal team member who meets these specifications based on staff availability)
Therapist race or ethnicity: e.g. Black
Therapist gender identity: e.g. woman
Therapist language spoken (other than English): e.g. Spanish

(Note, we will not text prior to initial appointment, nor will Private Health Information ever be transmitted via text.)

Contact Information

Client Name *

First Last

Client Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Are you referring more than one individual from the same family/grouping?

Yes No

2nd Client Name

First Last

3rd Client Name

First Last

Parent/Guardian Name

First Last

Client Contact Phone Number

123-456-7890

Client Contact Email Address

example@provider.com

Client's Preferred Contact Method

Phone Call Email Text Message

Referrer's Name

If you are submitting this form on behalf of someone else, please enter YOUR full name here

Referrer's Phone Number

If you are submitting this form on behalf of someone else, please enter YOUR phone number

Referrer's Email Address

If you are submitting this form on behalf of someone else, please enter YOUR email address

Please note your client's appointment location preference:

(Note, we will not text prior to initial appointment, nor will Private Health Information ever be transmitted via text.)

Please provide insurance information (if applicable)

Renewal accepts Kentucky Medicaid through Managed Care Organizations - as well as a number of private insurance providers; if you or the person you're referring will not be opting to bill insurance for services, you can leave this field blank.

Insurance to be used for Renewal Services:

(e.g. Passport, Wellcare, etc.)

Policy ID:

(found on insurance card)

Reason for Referral

Why are you reaching out to us today?

By clicking submit above, the information on this form will be transmitted securely to staff at Maryhurst Renewal using end-to-end encryption through JotForm in full HIPAA compliance. A member of the team will be in touch shortly.

Appointment Request Form