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: info@lydiashope.com

Text/Call: (336) 692-3545

In network with: Amerihealth, CHBA, Healthy Blue, Partners, Vaya, and Wellcare.

Out of Network with: Blue Cross Blue Shield

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