First Resources Corp.

A Resource For The Community

BHIS Referral Form

Referral Date:

Individual's Name:

Guardian/Parent Name:

Address:

County of Residency:

Phone #:

Email:

Child Date of Birth:

Medicaid/MCO ID#:

Referral Source (Name/Company):

Referral Emal:

Referral Phone #:

Therapist Name/Location:

Therapist Email:

Therapist Phone #:

Reason for Referral and any additional information:

Therapy Notes/Assessments

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Referral and recent assessment/record received.
Within 2 business days outreach is initiated to confirm family wants services.
Within 2 days of confirmation to start services, funding is requested/case is assigned.
Generally within 7 days funding is approved and staff are notified.
Within 3 business days BHIS staff will schedule services with the parents.

Your referral form has been successfully submitted. Our referral team will be in contact with you soon!