Refer a Patient

If you have a patient who is struggling with Mental Health or Substance Use and is in need of additional or continuing care, please fill out one of the forms below. If you wish to continue treating a referral patient as they go through the Aspire365 program, arrangements can be made. For additional information, please contact us at (385) 352-9696.

Initiate Referral (3–5 minutes): You will be contacted via phone for further information about the patient to complete the referral process.

Submit Full Referral (8–10 minutes): The patient will be contacted via phone to schedule an admissions screening.

• Initiate Partial Referral

  "*" indicates required fields

  1Referrer

  2Client

  3Insurance

  LinkedIn

  This field is for validation purposes and should be left unchanged.

  Referral Agent's Name*

  Referring Organization*

  Phone*

  Email*

  Would you like to continue working with the Referred Patient?*

  Yes

  No

  Patient Name*

  First Last

  Patient Date of Birth*

  Month

  Day

  Year

  Patient State of Residence*

  State of ResidenceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific

  Patient Zipcode*

  Patient Email

  Patient Phone Number

  Patient Insurance Provider*

  Insurance Phone Number*

  Member/Subscriber ID*

  Group Number*

  Do you have secondary insurance?*

  Yes

  No

  Patient Secondary Insurance Provider*

  Secondary Insurance Phone Number*

  Secondary Insurance: Member/Subscriber ID*

  Secondary Insurance: Group Number*

  Referring Patient to:*

  Mental Health Program

  Substance Use Program

  Preventive Screening

  Insurance Pay or Cash Pay*

  Insurance

  Cash

  Insurance Provider*

  Member/Subscriber ID*

  Group Number*

  Insurance Phone Number*

  Do you have secondary insurance?*

  Yes

  No

  Secondary Insurance Provider*

  Secondary Insurance: Member/Subscriber ID*

  Secondary Insurance: Group Number*

  Secondary Insurance Phone Number*

  Is there anything else you'd like us to know?

  Aspire365 Fax Number: +1-(385)-287-1035

  Untitled

• Submit Full Referral

  "*" indicates required fields

  1Referrer Contact Info

  2Client Contact Info

  3Client Description

  4Upload Files

  Referral Agent*

  Patient

  Parent/Guardian

  Primary care provider

  IOP

  PHP

  Inpatient Hospital

  Residential Facility

  Other

  What is your role or relationship with the patient?*

  Referral Agent Name*

  First Last

  Referral Agent Phone*

  Referral Agent Email*

  Reason for Referral (2–3 sentences why you/your patient is seeking care)*

  Patient Name*

  First Last

  Patient Date of Birth*

  Month

  Day

  Year

  Patient Phone Number*

  Patient Email*

  Patient State of Residence*

  Select OneAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific

  Patient Zipcode*

  Patient Insurance Provider*

  Insurance Phone Number*

  Member/Subscriber ID*

  Group Number*

  Do you have secondary insurance?*

  Yes

  No

  Patient Secondary Insurance Provider*

  Secondary Insurance Phone Number*

  Secondary Insurance: Member/Subscriber ID*

  Secondary Insurance: Group Number*

  Is the patient currently or has previously received any form of the following mental health or substance abuse treatment?*

  Inpatient psychiatric hospitalization

  Drug or alcohol detox

  Drug or alcohol rehabilitation

  Substance Use Disorder (SUD) Intensive Outpatient Program (IOP)

  MH intensive outpatient/partial program

  Residential psychiatric placement

  Outpatient mental health services

  Court-ordered mental health or SUD programming

  School mental health programming/day treatment

  Outpatient SUD service

  Other

  Is the patient currently having active thoughts, plans, or intent to kill themselves?*

  Yes (Please contact 911, 988, or emergency services.)

  No

  Is the patient reporting current thoughts, plans, or intent to harm or kill others?*

  Yes (Please contact 911, 988, or emergency services.)

  No

  Is the patient currently experiencing 2 or more of the following; hallucinations, hearing voices, paranoia, disorganized thinking, or impaired judgement?*

  Yes

  No

  Is the patient currently abusing drugs and/or alcohol?*

  Yes

  No

  Describe by providing the type of drug, frequency, amount, how long the drug has been used, and the last use of the drug by the patient.*

  Does the patient have a history of abusing drugs and/or alcohol?*

  Yes

  No

  Describe by providing the type of drug, frequency, amount, how long the drug has been used, and the last use of the drug by the patient.*

  Is the patient actively taking any of the following: Ativan (Lorazepam) 2mg or more daily Clonazepam (Klonopin) 0.5mg or more daily, Xanax (Alprazolam) 1mg or more daily, Valium (diazepam) 10mg or more daily?*

  Yes

  No

  Specify which medication, the dose amount, frequency, and the last use by the patient.*

  List all of the patient's current medications*

  List any current medical conditions or diagnoses of the patient.*

  Is the patient willing to use telehealth services?*

  Yes

  No

  Does the patient have ability to use telehealth (i.e. access to a computer, IPad, or phone w/ camera)?*

  Yes

  No

  If the patient is below the age of 18, do they have a parent or guardian willing to engage with the client's mental health providers weekly?*

  Yes

  No

  N/A

  Is the patient currently in the foster care system?*

  Yes

  No

  N/A

  Is the patient and/or family legally required to participate in mental health treatment?*

  Yes

  No

  Describe.*

  Does the patient have an intellectual disability or cognitive impairment?*

  Yes

  No

  Describe.

  Does the patient have a history of concussions and/or traumatic brain injury?*

  Yes

  No

  Describe.*

  Does the patient report currently or historically struggling with binging, purging, or purposefully restricting the amount they eat or holding a formal eating disorder diagnosis?*

  Yes

  No

  Provide the patient's height and weight, average calories consumed in a day, frequency of binging/purging, and if they are currently receiving any medical treatment for the above.*

  Upload a copy of the client's insurance card, front and back.*

  Drop files here or Select files

  Max. file size: 64 MB, Max. files: 2.

  Attach any relevant documents such as any psychiatric records (inpatient, partial, residential, outpatient, IOP), IEP/504 plan, psychological testing, etc.

  Drop files here or Select files

  Max. file size: 64 MB.

Refer a Patient

If you have a patient who is struggling with Mental Health or Substance Use and is in need of additional or continuing care, please fill out one of the forms below. If you wish to continue treating a referral patient as they go through the Aspire365 program, arrangements can be made. For additional information, please contact us at (385) 352-9696.

Initiate Referral (3–5 minutes): You will be contacted via phone for further information about the patient to complete the referral process.

Submit Full Referral (8–10 minutes): The patient will be contacted via phone to schedule an admissions screening.

• Submit Partial Referral

  "*" indicates required fields

  1Referrer

  2Client

  3Insurance

  LinkedIn

  This field is for validation purposes and should be left unchanged.

  Referral Agent's Name*

  Referring Organization*

  Phone*

  Email*

  Would you like to continue working with the Referred Patient?*

  Yes

  No

  Patient Name*

  First Last

  Patient Date of Birth*

  Month

  Day

  Year

  Patient State of Residence*

  State of ResidenceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific

  Patient Zipcode*

  Patient Phone Number

  Patient Email

  Patient Insurance Provider*

  Insurance Phone Number*

  Member/Subscriber ID*

  Group Number*

  Do you have secondary insurance?*

  Yes

  No

  Patient Secondary Insurance Provider*

  Secondary Insurance Phone Number*

  Secondary Insurance: Member/Subscriber ID*

  Secondary Insurance: Group Number*

  Referring Patient to:*

  Mental Health Program

  Substance Use Program

  Preventive Screening

  Insurance Pay or Cash Pay*

  Insurance

  Cash

  Insurance Provider

  Is there anything else you'd like us to know?

  Aspire365 Fax Number: +1-(385)-287-1035

• Submit Full Referral

  "*" indicates required fields

  1Referrer Contact Info

  2Client Contact Info

  3Client Description

  4Upload Files

  Referral Agent*

  Patient

  Parent/Guardian

  Primary care provider

  IOP

  PHP

  Inpatient Hospital

  Residential Facility

  Other

  What is your role or relationship with the patient?*

  Referral Agent Name*

  First Last

  Referral Agent Phone*

  Referral Agent Email*

  Reason for Referral (2–3 sentences why you/your patient is seeking care)*

  Patient Name*

  First Last

  Patient Date of Birth*

  Month

  Day

  Year

  Patient Phone Number*

  Patient Email*

  Patient State of Residence*

  Select OneAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific

  Patient Zipcode*

  Patient Insurance Provider*

  Insurance Phone Number*

  Member/Subscriber ID*

  Group Number*

  Do you have secondary insurance?*

  Yes

  No

  Patient Secondary Insurance Provider*

  Secondary Insurance Phone Number*

  Secondary Insurance: Member/Subscriber ID*

  Secondary Insurance: Group Number*

  Is the patient currently or has previously received any form of the following mental health or substance abuse treatment?*

  Inpatient psychiatric hospitalization

  Drug or alcohol detox

  Drug or alcohol rehabilitation

  Substance Use Disorder (SUD) Intensive Outpatient Program (IOP)

  MH intensive outpatient/partial program

  Residential psychiatric placement

  Outpatient mental health services

  Court-ordered mental health or SUD programming

  School mental health programming/day treatment

  Outpatient SUD service

  Other

  Is the patient currently having active thoughts, plans, or intent to kill themselves?*

  Yes (Please contact 911, 988, or emergency services.)

  No

  Is the patient reporting current thoughts, plans, or intent to harm or kill others?*

  Yes (Please contact 911, 988, or emergency services.)

  No

  Is the patient currently experiencing 2 or more of the following; hallucinations, hearing voices, paranoia, disorganized thinking, or impaired judgement?*

  Yes

  No

  Is the patient currently abusing drugs and/or alcohol?*

  Yes

  No

  Describe by providing the type of drug, frequency, amount, how long the drug has been used, and the last use of the drug by the patient.*

  Does the patient have a history of abusing drugs and/or alcohol?*

  Yes

  No

  Describe by providing the type of drug, frequency, amount, how long the drug has been used, and the last use of the drug by the patient.*

  Is the patient actively taking any of the following: Ativan (Lorazepam) 2mg or more daily Clonazepam (Klonopin) 0.5mg or more daily, Xanax (Alprazolam) 1mg or more daily, Valium (diazepam) 10mg or more daily?*

  Yes

  No

  Specify which medication, the dose amount, frequency, and the last use by the patient.*

  List all of the patient's current medications*

  List any current medical conditions or diagnoses of the patient.*

  Is the patient willing to use telehealth services?*

  Yes

  No

  Does the patient have ability to use telehealth (i.e. access to a computer, IPad, or phone w/ camera)?*

  Yes

  No

  If the patient is below the age of 18, do they have a parent or guardian willing to engage with the client's mental health providers weekly?*

  Yes

  No

  N/A

  Is the patient currently in the foster care system?*

  Yes

  No

  N/A

  Is the patient and/or family legally required to participate in mental health treatment?*

  Yes

  No

  Describe.*

  Does the patient have an intellectual disability or cognitive impairment?*

  Yes

  No

  Describe.

  Does the patient have a history of concussions and/or traumatic brain injury?*

  Yes

  No

  Describe.*

  Does the patient report currently or historically struggling with binging, purging, or purposefully restricting the amount they eat or holding a formal eating disorder diagnosis?*

  Yes

  No

  Provide the patient's height and weight, average calories consumed in a day, frequency of binging/purging, and if they are currently receiving any medical treatment for the above.*

  Upload a copy of the client's insurance card, front and back.*

  Drop files here or Select files

  Max. file size: 64 MB, Max. files: 2.

  Attach any relevant documents such as any psychiatric records (inpatient, partial, residential, outpatient, IOP), IEP/504 plan, psychological testing, etc.

  Drop files here or Select files

  Max. file size: 64 MB.