Refer Your Patient to Novus Health

New Client Referral Form

Primary Care| HIV Care | Psych Assessment | Behavioral Health Counseling
Date

MonthDayYear
Date
Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Sex at Birth*

MaleFemale
Current Gender Identity*

MaleFemaleTransgender (M2F)Transgender (F2M)Other
Sexual Orientation

Lesbian, gay or homosexualStraight or heterosexualBisexualSomething else, please describeOther
Race*

Black or African AmericanWhite/ CaucasionAsianNative HawaiianPacific IslanderAmerican Indian/Alaska Native
Ethnicity*

Hispanicnon-Hispanic
Home Phone
Is it okay to leave appointment information on the cell phone?

YesNo
Cell Phone
Is it okay to leave appointment information on the home phone?

YesNo
Patient's Email
example@example.com
Preferred way of contact (choose all that apply)

Call cell phoneText messageCall home phoneEmail
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What County Do You Live In?*
Does the patient have insurance?*

YesNo
If yes, Name of insurance
Subscriber no
What Type of Referral is This?*

Behavioral Health (counseling)Psychiatric Assessment (only)MATPrimary Care (PCP)PrEPHIV Care
HIV / PCP Provider Name
Provider Phone Number
Please enter a valid phone number.
Reason for Psych Assessment, Behavioral Health Referral (Mental Health concern or Mental Health Diagnosis):*
Referring Facility Information
Is the patient enrolled in a Ryan White Program?*

YESNO
Case Manager/ Office Staff Name
Case Manager Company/ Facility Name
Phone number
Fax Number
Contact person's Email
example@example.com
RYAN WHITE INFORMATION
Ryan White ID (HSI / DCN) Number:
Year of HIV Diagnosis:
HSI Start Date:
HSI end (renewal due) date:
Which Referral is currently active for the client?*

STLHD - Mental Health ServicesHSI - Mental Health Counseling Co-paysNone of these
STL TGA CS MGMT Referral Start date
STL TGA CS MGMT Referral end date
Ryan White Case Manager Name:
Case Manager Company/ Facility Name
Contact person's Email
example@example.com
Phone number
Fax Number
The referral form will automatically be submitted.

For further information, please contact our intake scheduler Randy Fenley at:

Tel: 314-652-0100 ext. 134 / Fax: 314-652-0125 /

Email: randy@novushealthstl.org
Should be Empty:

New Client Referral Form

Patient Information

Referring Facility Information

RYAN WHITE INFORMATION