Referral Form

We appreciate you referring clients to us. Please complete the form below and we will contact them for an intake appt.

Feel free to email us at: admin@lydiashope.com with questions.

Text/Call: (336) 692-3545

In network with:

Medicaid: Amerihealth, Healthy Blue, Partners, Vaya, UCH Community Care and Wellcare.

Commercial: Aetna, BCBS, CBHA, Medcost

Out of Network: Cigna and United Health Care Commercial

Sliding Scale available. Intern pricing available. Contact admin@lydiashope.com for details.

Patient Name

First Name

Last Name

Date of Birth

YYYY

Parent/Guardian Name

Insurance Type

Medicaid Number

Doctor Name and Practice Name

Doctor Phone

(###)

###

####

Parent/Guardian Email

Parent/Guardian phone

(###)

###

####

Reason for Referral

Name of Person making referral

First Name

Last Name