Client Referral [raw] Syntero Referral for Services Form Fill out this convenient form to email your referral to Syntero. Or, click here if you would rather fill out a PDF version of this form that you can download and fax to us. Referring Agency Information Date of Referral Agency/Contact Name Phone Number Client Information Parent/Guardian Name if Client is a Minor Client's First Name Client's Last Name Client's Date of Birth Client's Current Age Client's SSN Client's Street Address Client's City Client's State Client's Zip Code Client's Primary Phone# Client's Secondary Phone# May we say Syntero is Calling? Yes No May we leave a message? Yes No Client's Email Address Client's Primary Language Interpreter Needed? Yes No Presenting Issue(s) Check All That Apply Alcohol/Drug Divorce Anger Sexual Abuse/Harassment Court Ordered Assessment ADHD Relationship/Marital LGBTQ Issues Trauma Chronic Pain Depression Family Child Behavioral Issues Stress/ Anxiety Life Transition Issues Other If you selected "Other" in the section immediately above please explain. Are Drugs or Alcohol a Concern at This Time? Yes No Preferred Service Type Individual Family Couples Group IOP Other If you selected "Other" in the section immediately above please explain. Insurance Information Complete insurance information to facilitate faster access to services. Insurance Name Policy Number Medicaid policy numbers contain 12 digits Group Number or Name Policy Holder's Name Policy Holder's DOB Preferred Syntero Location Dublin Mill Run Northeast Lewis Center How did you hear about Syntero? Currently Work with Syntero Have worked with Syntero in the past Website/internet search Word of mouth School Pediatrician or Primary Care Provider Other If you selected "Other" in the section immediately above please explain. Are you human?(required) This field should be left blank Submit Please wait... [/raw]
