Shepherd of The Valley Request Form

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Shepherd of The Valley Request Form

Shepherd of The Valley Request FormAdmin2022-05-28T11:04:28+00:00

If you have any questions, please call our client specialists at 651.313.8080 between the hours of 8:30 am and 5:00 pm CST Monday through Friday. We can help you find the appropriate services and schedule your first appointment.

Before we get started, please have your insurance information and medical history.

Name

Email Address *

Client Name

Client Date of Birth *

This is for mental health

Are you interested in medication management?

Referral Date

Sex: *

PMI# *

Insurance Provider *

* Before KESMA Flame Lily 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 *

Address *

Street Address Line 2 *

City *

State / Province *

ZIP / Postal Code *

Country

Phone Number *

Does this person have a Legal Guardian?

If yes, Guardian Name *

Guardian Phone Number *

Phone Number

Social Worker

Social Worker Phone Number *

Phone Number *

Diagnosis * *

Language Preference * *

Is an 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

Referring Party Phone Number *

Phone Number *

Referring Party Email Address * *

Any additional information to help find a good match for an ARMHS practitioner please write below:

How did you hear about us?

Internet Search (Google)Friend or Family MemberAnother Provider (ie. Doctor, case manager)An online advertisement (Facebook/YouTube)Other Media (i.e. radio or TV)NewsletterAt a Community Event (ie. resource fair, presentation)Others

As soon as we receive a referral, KESMA Flame Lily 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.