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If you have difficulty submitting this form, email
a copy of the form to
admin@oneheartt.org
Front and back of insurance card and government ID are required
For Documents
Upload Front of Insurance Card
Upload supported file (Max 15MB)
For Documents
Upload Back of Insurance Card
Upload supported file (Max 15MB)
For Documents
Upload Gov Issued ID
Upload supported file (Max 15MB)
Type of Referral
*
आवश्यक
Self
Parent/Guardian
Professional
Professional-Non Therapeutic
Services requested
Does the patient have secondary insurance
*
आवश्यक
Yes
No
Does the patient have a guardian?
*
आवश्यक
Yes
No
Employment Status
Marital Status
Is the patient of Hispanic or Latin origin?
*
आवश्यक
Yes
No
Has the patient participaed in a self-help group in the past 30 days?
*
आवश्यक
Yes
No
Is the patient a veteran?
*
आवश्यक
Yes
No
Is the patient pregnant? (Female only)
Yes
No
For Pictures
Upload Front of Insurance Card
Upload supported file (Max 15MB)
For Pictures
Upload Back of Insurace Card
Upload supported file (Max 15MB)
For Pictures
Upload Gov Issued ID
Upload supported file (Max 15MB)
Living Situation
Do you have the primary care info?
*
आवश्यक
Yes
No
Are you a hurricane victim
*
आवश्यक
Yes
No
Is the patient currently recieving mental health treatment
*
आवश्यक
Yes
No
Highest level of education completed
Any arrests in the past 30 days?
*
आवश्यक
Yes
No
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