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To initiate services with Choice Health Integrated, please complete this form and send with required documentation to our office.

If you have questions, please email us at pshreferrals@choicehealthaz.com or call us at 480-527-0037.

Today'Date*

First name*

Last name*

Phone

Email*

Date of Birth*

Month

Day

Year

Individual is aware of and in agreement with referral. (If "No" please obtain consent before proceeding.)*

Yes

No

Guardian Name and Contact Info (if applicable)

Primary Language:*

Multi-line address

Country/Region

Address

City

Zip / Postal code

AHCCCS ID*

Multi choice*

AHCCCS/Title 19

SMI

GMH

T 19

NT 19

Other Insurance

Other Insurance ID

Eemergency Contact Name*

Emergency Contact Phone*

Service Requested

PSH Housing Support Services (SMI T19 & NT19)

Counseling

Psych/PCP Services

IOP - Mental Health/Substance Use Disorder

Nutritionist

Peer Support Training

Live Better Program: (IOP + Sober Living) GMH & SMI T19 Only

Name of Referring Agency (specific clinic or loca􀟒on)*

Referring Case Manager's Name*

Case Manager' Phone #*

Case Manager's Email*

Clinical Coordinator Name*

Clinic Coordinator's Phone #*

Name of Staff Member Signing Referral Form*

Staff Member's Signature

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Date*

REQUIRED DOCUMENTS

Release of Information*

Guardianship/COT Documents, if applicable

Outpatient Assessment*

Individual Service Plan/Treatment Plan*

Medication List

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