Open Access Client Intake (TEAMS/client)

TEAMS LLC - Referral & Intake Form

Please enter a referral code to get started

Referral Code:

Referral Code:

Who Do We Have The Pleasure Of Serving Today? All fields in blue are required.

First Name:

Last Name:

Middle Name:

Suffix:

Date Of Birth:

Gender:

Male

Female

Unknown

Street:

City:

County:

State:

Zip:

Health Plan:

Social Security #:

Insurance Name:

Insurance Id No:

Tell Us More

Home Tel:

Bus Tel:

Cell Tel:

Maiden Name:			Nickname:

Maiden Name:

Nickname:

Marital Status:

Race:

Ethnicity:

Guardian name (if under 18)			Guardian Relationship

Guardian name (if under 18)

Guardian Relationship

Guardian Email:

Guardian Email:

Referred by (name):		Referral Source:

Referred by (name):

Referral Source:

Referrer Tel:	Referrer other contact info:
Direct/Self Referral Entered by Staff :

Why Are You Here Today?

Client Disposition at Referral :

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File To Upload:

TEAMS LLC can only receive complete referrals. A complete referral includes your information and the contact information for the parent or legal guardian (if applicable). Also, if the child is currently receiving MH services, the most current CCA and PCP must be submitted.

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