ACT Referral Form

Submit a referral to The Well’s ACT Program.

Important: This form is for referring agencies only. If you are a current or prospective client, please do not complete this form—visit thewellne.org or call us at 402-371-0220.

Information About the Person You Are Referring

Please enter the details for the individual you are referring to The Well ACT Program.

First Name*

Last Name*

Date of Birth

Format: mm/dd/yyyy

SSN

Primary Phone

Mobile Phone

Primary Email

Gender

Address

Street

City

State

Zip Code

Referring Agency Contact

Referring Agency

Referral Contact First Name

Referral Contact Last Name

Email Address of Person Making Referral

Phone Number of Person Making Referral

Insurance

Insurance Provider

If unsure, choose “Other” and add details in “Reason for Referral.”

Primary Insurance - Policy Number

Primary Insurance - Group Number

Clinical Information

Primary Mental Health Diagnosis

Has this person received 2 or more inpatient admissions in the last 24 months?

If yes — list facility name and dates

Has this person received 3 or more months of residential care in the last 12 months?

If yes — list facility names and dates

Has this person received 4 or more weeks of emergency hospitalizations in the last 12 months?

If yes — list facility names and dates

Behavioral Health Services (last 2 years)

Please list in chronological order, including facility names and dates if possible.

Legal Status

MHB Commitment Parole or Probation NRRI Voluntary

If MHB Commitment or NRRI — list county of commitment

Appointed guardian (name + phone)

Appointed payee (name + phone)

Current Psychiatrist

Current Psychiatric medications and dosage

Physical Health Condition or Diagnosis

Current Physical Health Medications and Dosage

Reason for Referral

What is the presenting problem and why is it necessary for services now? How is the presenting problem impacting their mental health symptoms/recovery? What are the specific symptoms that are creating the need for these services?

ACT Referral Form

Referral Submitted