ASCENT MEMPHIS

Who Can Make a Referral?

Anyone that knows the individual can make a referral. Ascent receives referrals from parents, relatives, schools, teachers, counselors, mental healthprofessionals, probation officers, etc. Ascent works mostly with individuals that meet the qualifying criteria through Amerigroup insurance.

In addition, Ascent can provide standard outpatient counseling services for those who need assistance.

Next Steps:

After you have submitted a referral form, you will be contacted by one of our Ascent representatives.

Today's Date

MM

DD

YYYY

Youth's Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Social Security Number

Amerigroup Number

Primary Care Physician

Primary Care Physician's Name of Practice

Primary Care Physician's Location of Practice

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Legal Guardian Name

First Name

Last Name

Legal Guardian's Phone 1

(###)

###

####

Legal Guardian's Phone 2

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of youth's placement, if different from guardian

(Ex. Agency Name, Family Friend, Teacher, Relative, etc.)

Referring Source

Referring Source Email

Contact Person

First Name

Last Name

Contact Phone Number

(###)

###

####

Reason For Referral

Comments/ Additional Information

Is the family comfortable with face to face visits at this time?

yes

no

Comments/ Additional Information