Submit an SOTV Referral Your Name Your Email Client First Name Client Last Name DOB This is for maternal mental health Are you interested in medication management? YesNo Referral Date Sex PMI# Insurance Provider * Before Ellie Family Services can begin providing services to any client, we MUST have the insurance carrier, member ID # and group number as it appears on their member ID card. For example, if a client has PMAP coverage, we will need the specific PMAP plan information (insurance provider name, member ID and group #), before we can schedule an intake. If a client has straight Medical Assistance, we will just need their MA/PMI # Insurance Member ID Insurance Group # Age Street Address City Zip Code County Phone Legal Guardian YesNo If yes, Guardian Name Number Social Worker Phone Number Diagnosis Language Preference Interpreter Needed? YesNo Gender Availability Does the client smoke? If so, do they smoke in their home? Does the client have pets? If so, what kind? Referring Party: Please include your contact information: Any additional information to help find a good match for a practitioner please write below: As soon as we receive a referral, Ellie staff will begin processing and verifying insurance coverage. If a client has "inactive" insurance, we will not be able to schedule an intake until we have confirmed that insurance is active. If a client has a PMAP plan, and we do not have the plan name, member ID and group numbers, we will not be able to schedule an intake. We will work with you, the referral source, to work on ensuring that coverage is in place. Thank you for working with us. We appreciate the support and assistance in coordination.