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Outpatient Referral Form

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Outpatient Referral Form

We are happy to accept referrals and questions.

Cedar Rapids: (319) 286-4545 or therapyreferral@tanagerplace.org

Coralville: (319) 286-4520 or CoralvilleBHC@tanagerplace.org

If you prefer, a PDF version of this form is available for download.

Date
Date Format: MM slash DD slash YYYY
Referral Source (name/agency)*
Client Name*
First Last
Client Date of Birth*
Date Format: MM slash DD slash YYYY
Client Age*
Client Gender*
Client Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian Name*
First Last
Relationship to Client*
Parent/Guardian Phone Number*
Parent/Guardian Email Address
Providing an email address, if available, helps us connect you to needed services as efficiently as possible.
Current Services & Providers*
Current Tanager Place client?*
- Yes
- No
Date of Last Assessment
Date Format: MM slash DD slash YYYY
Recommended Services
Outpatient Therapy:
- Cedar Rapids Clinic
- Coralville Clinic
- School Based (provide school name)
School Name, if applicable:
Psychiatric Services:
- Medication Management
- Psychological Testing
Autism Services:
- Social Skills Group
- Testing/Assessment
- ABA Services (include documentation showing medical diagnosis below)
Reason for Referral:*
Please include information about current symptoms, behaviors, functioning and trauma
Insurance & Documentation
Please attach copy of insurance card and ABA documentation, if applicable, in upload section below. Insurance verification required before appointment. Tanager Place is unable to accept Medicare insurance at this time. Private pay rates are available for insurances out of network. While insurance information is not required as part of this form, providing it now will expedite the path to treatment.
Medicaid/MCO ID Number:
Name on Medicaid/MCO Card:
First Last
Private Insurance: Subscriber's Name
First Last
Private Insurance: Subscriber's Date of Birth
Date Format: MM slash DD slash YYYY
Private Insurance: Policy Number/Member ID
Private Insurance: Group Number/Plan Name
Private Insurance: Employer Name
Insurance & Documentation Upload
Drop files here or

Accepted file types: jpg, pdf, png, gif.
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Accredited by Council on Accreditation of Services

Main Office

2309 C St SW
Cedar Rapids, IA 52404

Phone: 319-365-9164
Fax: 319-365-6411

Estle Center

1030 5th Ave SE
Cedar Rapids, IA 52403

Phone: 319-286-4545
Fax: 319-368-3358

Coralville Clinic

1150 5th St Suite 160
Coralville, IA 52241

Phone: 319-286-4520

Camp Tanager

1614 W Mt. Vernon Rd
Mt. Vernon, IA 52314

Phone: 319-363-0681
(Off Season: 365-9164)

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