Mental Health Skill Building (MHSB) Referral Form

Instructions: Please complete this form to refer an individual for Mental Health Skill Building services. All submissions are processed securely through our online system.

I. REFERRER INFORMATION

Referrer Name *

Organization/Agency *

Title/Relationship to Client

Referrer's Email *

Referral Phone Number *

Date of Referral *

II. CLIENT INFORMATION

Full Name *

Date of Birth *

Gender *

Phone *

Email *

Address

Street Address

City

State

Country

Enter your country

Postal Code

III. INSURANCE & MEDICAID ELIGIBILITY

MHSB services require active insurance verification. Please provide Medicaid or private insurance details below.

Primary Insurance Provider *

Medicaid / Member ID Number *

Managed Care Organization (MCO) (e.g., Anthem, humana, Sentara, etc.)

Medicaid / MCO Service Requirement Notice:

To qualify for Medicaid-funded MHSB services, the individual must meet specific medical necessity criteria, including a qualifying mental health diagnosis and a documented clinical history of psychiatric treatment or stabilization needs.

IV. CLINICAL ELIGIBILITY & FUNCTIONAL IMPAIRMENTS

Check all that apply. MHSB typically requires a qualifying diagnosis and functional impairment.

1. Qualifying Diagnosis (DSM-5 / ICD-10): *

Choose one or more options

Other Qualifying Diagnosis

2. Psychiatric Service History (Within the last 12–24 months): *

Choose one or more options

Is the client currently prescribed psychotropic medication?

Yes

3. Functional Impairments (Areas requiring skill-building intervention): *

Choose one or more options

V. REASON FOR REFERRAL & CLINICAL SUMMARY

Please briefly describe the individual's current mental health presentation, why they require MHSB services, and their primary goals:

Reason for Referral

VI. ACKNOWLEDGEMENT & CONSENT

Is the client/guardian aware of and consenting to this referral? *

Select an option

Referral Signature *

Clear

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.