Client Intake Referral | Family Unity & Connection Center

Incoming Client Intake

Complete this form to refer a client to Family Unity & Connection Center for services.

Client Information

First Name *

Required.

Last Name *

Required.

Date of Birth *

Required.

Email Address *

Enter a valid email.

Client Phone Number (can receive texts) *

Enter a valid 10-digit phone number.

Street Address *

Required.

City *

Required.

State *

Required.

ZIP

Insurance Information

Insurance Company * e.g., CareSource, Buckeye, Molina, Aetna, UnitedHealthcare, Anthem, etc.

Required.

Insurance Member ID

Medicaid ID / MMIS Number

Social Security Number * Required only if a Medicaid ID/MMIS and Member ID are not both provided. Used solely to verify coverage.

SSN is required unless both a Medicaid ID and an Insurance Member ID are provided.

Minor / Guardian

This client is a minor (age is automatically detected from the date of birth above; you may also check this manually).

Referral Source

How is this client being referred? *

Required.

Reason for Referral (optional)

Notes / Presenting Concern