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Referral
Please complete this form and then click submit.
Referring Agency/Clinic/Provider
Date of Referral
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Provider Fax Number
Contact Person
Patient Name
Patient Date of Birth
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Patient Email
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Magellan EAP
Concern Health, EAP
Amerigroup
Aetna
BCBS
Cigna
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BlueCare
TennCare Select
CoverKids
United Healthcare (commercial)
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Reason For Referral
Anxiety
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Anger Mgmt
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Trauma
Family Issues
Suicidal Ideation (no plan)
Stress
Other
Preferred Team Member
Morenike Murphy
Aisha Lee
Dr. Chatiqua Miller
Delora Ruffin
Demetria Fields
Donna Ross
Jae Porter
Julia Neilan-Keaton
Dr. Lametria Johnson
Clincal concern to be addressed
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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.
