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.