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Please complete this form and then click submit.
Referring Agency/Clinic/Provider
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Provider Fax Number
Contact Person
Patient Name
Patient Date of Birth
Patient Phone Number
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Magellan EAP
Concern Health, EAP
Amerigroup
Aetna
BCBS
Cigna
ComPsych
BlueCare
TennCare Select
CoverKids
United Healthcare (commercial)
Self Pay
Reason For Referral
Anxiety
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Self Esteem
Anger Mgmt
Substance Abuse
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Family Issues
Suicidal Ideation (no plan)
Stress
Other
Preferred Team Member
Morenike Murphy
Aisha Lee
Delora Ruffin
Demetria Fields
Donna Ross
Jae Porter
Julia Neilan-Keaton
Dr. Lametria Johnson
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Primary Insurance Information
Magellan Healthcare
Concern Health, EAP
BCBS
Cigna
ComPsych
BlueCare
TennCare Select
CoverKids
United Healthcare
Self Pay
Reason For Referral
Anxiety
Depression
Grief/Loss
Self Esteem
Anger Mgmt
Substance Abuse
Trauma
Family Issues
Suicidal Ideation (no plan)
Stress
Other
Preferred Team Member
Morenike Murphy
Jaime Harper
Wanda Key
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Recovery Support
Mental Health
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Your Referral was submitted.
