Summit Psychological Associates, Inc. Return to: [email protected] Intake Phone: 234.718.2331 Intake Fax: 234.571.9107 ☐ North Akron 557 N Main St Akron, OH 44310 Ph: 330.787.0031 Fx: 234.900.6016 DOB: SSN: E-mail: Phone: Client's Name: Gender: Street Address: City, State, Zip: Main Phone: Other Phone: Referring Organization: Contact Name: Psychological Evaluation Treatment Assessment SMART Program/Vivitrol MAT Payment Type: Client's Medicaid/Medicare # REFERRAL FORM Choose the Service Location Client's Insurance Treatment Request Choose All That Apply This service includes a clinical interview, review and incorporation of pertinent records and administration of psychological testing as needed, and a formal written report. This service includes a standard intake with a clinician that is followed by development of a treatment plan and initiation of treatment. This service provides comprehensive mental health and substance abuse services for individuals suffering with opiate or alcohol addiction. Reason for Referral - Please explain and choose a service Thinking for a Change New Foundation Drug and Alcohol 26 Week Program New Foundation Drug and Alcohol 12 Week Program Drug and Alcohol 6 Week Education Program (Sober Success - Portage County Jail Only) Pride in Parenting 10 Week Program Individual Mental Health Counseling (based on assessment or evaluation) New Directions - 12 week trauma based program for prostitution or sex trafficking victims Freespace Program HOPE Program Other Adult Sex Offender Treatment Program Juvenile Sex Offender Treatment Program Conflict Solutions Anger Management - 26 Week Program (no assessment or eval needed) Conflict Solutions Anger Management - 10 Week Program (no assessment or eval needed) TOD Program (Family Violence Court Referrals Only) 52 Week Battered Intervention Program (Summit County Court of Common Pleas-Domestic Violence Docket Only) Anger Management Batterers Intervention Program (Only referrals from Summit County Judge Gallagher's Court) Restoration Treatment DATE: Insurance Provider Member ID Client is Self-Pay Fax: ☐ Akron 37 N Broadway Akron, OH 44308 Ph: 330.535.8181 Fx: 330.535.9303 Ravenna Chestnut Medical Arts Bldg 6693 N. Chestnut St., #235 Ravenna, OH 44266 Ph: 330.296.3700 Fx: 330.298.1460 Female Male Transgender Referring Organization will be Billed ATP Funding ☐ Canton 832 McKinley Ave NW Canton, OH 44703 Ph: 330.493.2554 Fx: 330.493.9520 ☐ Fremont Brady Building Suite 301 219 S. Front St. Fremont, OH 43420 Ph: 567.432.5070 Fx: 567.314.0010 Tiffin 65 St. Francis Ave. Tiffin, OH 44883 Ph: 567.220.7018 x 4212

REFERRAL FORM - Summit Psychological · Summit Psychological Associates, Inc. Return to: [email protected] Intake Phone: 234.718.2331 Intake Fax: 234.571.9107 ☐

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Page 1: REFERRAL FORM - Summit Psychological · Summit Psychological Associates, Inc. Return to: referral@summit-psychological.com Intake Phone: 234.718.2331 Intake Fax: 234.571.9107 ☐

Summit Psychological Associates, Inc. Return to: [email protected]

Intake Phone: 234.718.2331Intake Fax: 234.571.9107

☐ North Akron557 N Main StAkron, OH 44310Ph: 330.787.0031Fx: 234.900.6016

DOB:SSN:

E-mail:

Phone:

Client's Name: Gender:Street Address: City, State, Zip: Main Phone: Other Phone: Referring Organization: Contact Name:

Psychological Evaluation

Treatment Assessment

SMART Program/Vivitrol MAT

Payment Type: Client's Medicaid/Medicare #

REFERRAL FORM

Choose the Service Location

Client's Insurance

Treatment Request Choose All That Apply

This service includes a clinical interview, review and incorporation of pertinent records and administration of psychological testing as needed, and a formal written report.

This service includes a standard intake with a clinician that is followed by development of a treatment plan and initiation of treatment.

This service provides comprehensive mental health and substance abuse services for individuals suffering with opiate or alcohol addiction.

Reason for Referral - Please explain and choose a service

Thinking for a Change

New Foundation Drug and Alcohol 26 Week Program

New Foundation Drug and Alcohol 12 Week Program

Drug and Alcohol 6 Week Education Program (Sober Success - Portage County Jail Only)

Pride in Parenting 10 Week Program

Individual Mental Health Counseling (based on assessment or evaluation)

New Directions - 12 week trauma based program for prostitution or sex trafficking victims

Freespace Program

HOPE Program