Client Referral

Polara Health Referral Form
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Client Referral to Polara Health

* Indicates required field

Referral Date *

Referral Source *

Client Name *

First

Last

Client DOB: *

Client Age *

Client Gender at Birth *

Client Gender Identity *

Guardian Name and Relationship (if applicable) *

Contact Number *

Email address *

Physical Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact *

First

Last

Emergency Contact Phone Number *

Insurance Information

AHCCCS ID *

AHCCCS Health Plan *

Other Insurance *

Policy # *

Group # *

Policy Holder *

Preferred Clinic Location *

Prescott Prescott Valley Chino Valley Verde Valley

Reason for Referral *

All Referrals will be contacted within 1 business day and offered an intake within 7 days.

Upload Client Information *

Max file size: 20MB

Upload Additional Information *

Max file size: 20MB

Submit

BEFORE YOUR FIRST VISIT

Are you preparing for your first appointment with us?
These documents may be helpful as you get ready:

For information in another language call: (928) 445-5211.
Para información en Español llame: (928) 445-5211 ext 3198 or ext. 2016

CONTACT US

Walk In Crisis Location:
8655 E. Eastridge Drive
Prescott Valley, AZ 86314
Hours: Open 24 hours, 7 days a week
Crisis helpline: 928-445-5211 X1
A telehealth specialist is ready to take your call.

Telehealth - Zoom Information
The Zoom Link: https://zoom.us
Meeting ID: 954 0369 1857
Passcode: 946460

The Telephone Numbers
Dial/join by phone
1-253-215-8782 or
1-346-248-7799
Meeting ID: 954 0369 1857
Passcode: 946460

CLIENT REFERRAL TO POLARA HEALTH

Client Referral to Polara Health

​BEFORE YOUR FIRST VISIT

CONTACT US

BEFORE YOUR FIRST VISIT