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

Initiate Partial Referral
Submit Full Referral

1Referrer

2Client

3Insurance

Referral Agent's Name*

Referring Organization*

Phone*

Email*

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

Yes

Patient Name*

First Last

Patient Date of Birth*

Month

Day

Year

Patient State of Residence*

Patient Phone Number

Patient Email

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

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

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*

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.)

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

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

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

Yes

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

Yes

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

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

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

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

Yes

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

N/A

Is the patient currently in the foster care system?*

Yes

N/A

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

Yes

Describe.*

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

Yes

Describe.

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

Yes

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

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

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

Max. file size: 64 MB.

Refer a Patient

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

Submit Partial Referral
Submit Full Referral

1Referrer

2Client

3Insurance

Referral Agent's Name*

Referring Organization*

Phone*

Email*

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

Yes

Patient Name*

First Last

Patient Date of Birth*

Month

Day

Year

Patient State of Residence*

Patient Phone Number

Patient Email

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

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

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*

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.)

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

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

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

Yes

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

Yes

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

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.*

Yes

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

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

Yes

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

N/A

Is the patient currently in the foster care system?*

Yes

N/A

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

Yes

Describe.*

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

Yes

Describe.

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

Yes

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

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

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

Max. file size: 64 MB.

Aspire365 has earned The Joint Commission’s Gold Seal of Approval.