BBHSI NEWS
● To find out more about BBHSI, feel free to contact us. Our phone number is listed below, and we would love to hear from you.
● Beneficial Behavioral Health Services, Inc. ("BBHSI") began operations in 1999.
   
REFERRAL FORM
 
Referral Source Information:
 
Todays Date:
Referral Source Name and Title:
Referral Agency:
Referral Phone:
Email:
Referral Address:
 
Client Information:
 
Last Name:
First Name:
DOB:
Sex:
SSN #:
Medicaid #:
Ethnicity:
Current Placement:
Address:
City:
State:
Zip:
Home Phone:
Alternate Number:
Mothers Name:
Fathers Name:
 
Reason for Referral/Presenting Problem:
Other services required?  
Services Requested:
Individual Therapy In Office Psychological Eval ADHD Eval
Family Therapy In Home CTA CD Eval
CD Counseling Group Therapy Intensive Outpatient Other
You may require other service  
Insurance Information:
Primary
Medicaid/Kid’s Connection Blue Cross/Blue Shield United Healthcare
Magellan Region VI Coventry
Medicaid Midlands Choice Tricare
Douglas County Pay Self Pay
Secondary
Medicaid/Kid’s Connection Blue Cross/Blue Shield United Healthcare
Magellan Region VI Coventry
Medicaid Midlands Choice Tricare
Douglas County Pay Self Pay
 
Requested staff member for above services: