Trauma Therapy Referral Form Referrer Contact Information Today’s Date Name of Referrer ______Referrer Contact Information (Phone Number/Email Address) ______Please attach a release of information

Client Information Name ______Date of Birth  Adult  Child Anasazi Number ______ Female  Male Address City State Zip Code ______Phone Number Insurance Information MCO  Amerigroup  IME  Iowa Total Care ______Medicaid Number ______ Other (BCBS, private insurance): ______Guardian  Yes  No (If Yes, please provide name and phone number below.) Guardian Name(s) & Phone Number ______

Type of Crime: The below list is not intended to be reviewed item-by-item with the individual; please only complete with information as voluntarily shared.  Adult Physical Assault  Human Trafficking: Labor  Adult Sexual Assault  Human Trafficking: Sex  Adults Sexually Abused/Assaulted as Children  Identity Theft/Fraud/Financial Crime  Arson  Kidnapping (non-custodial)  Bullying (Verbal, Cyber, or Physical)  Kidnapping (custodial)  Burglary  Mass Violence (Domestic/International)  Child Physical Abuse or Neglect  Other Vehicular Victimization (e.g. Hit and  Child Pornography Run)  Child Sexual Abuse/Assault  Robbery  Domestic and/or Family Violence  Stalking/Harassment  DUI/DWI Incidents  Survivors of Homicide Victims  Elder Abuse or Neglect  Teen Dating Victimization  Hate Crime:  Terrorism (Domestic/International) Racial/Religious/Gender/Sexual Orientation/Other  Violation of a Court (Protective) Order  Other: ______OVER  Is the crime recent (less than a year ago)? If so, when did the crime occur? ______Does the client have transportation?  Yes  No Is it safe to leave a message for the client at the number provided?  Yes  No What days and times is it safe to call? ______Is it safe to mail information to the client at the home address provided?  Yes  No Has the client ever completed the Crime Victim’s Compensation Application?  Yes  No Does this client need an interpreter?  Yes  No If yes, for which language? ______

Do any of these apply to the person being referred?  Deaf/Hard of Hearing  Veterans  Homeless  Victims with Disabilities  Immigrants/Refugees/Asylum Seekers  Victims with Limited English Proficiency  LGBTQ  Other

Completed form and release can be emailed to [email protected]

Office use only: Date Received ______Therapist Assigned ______Paperwork Needed  HEAL screening  Save referral  Scan referral  CVA  Spreadsheet  Note