Repay, Inc.

Sexual Abuse Intervention Services  

Referral Form

Referring Agency:   _____________________             Referring Agency Contact:  __________________

Referring Agency County:  _______________             Referring Agency Phone:  __________________     

Referring Agency Medicaid#: ______________           Referring Agency Fax:  ___________________         

Referring Agency NPI# ______________________     Client/Guardian Phone: ___________________

Date of Referral:_______________________________  

Reason for Referral:________________________________________________________

AdultAdult's name: _______________________________________________________

*Adult's date of birth: ___________________

*Social Security No. *(MANDATORY)  ________________________

County of Residence:    _________________________         Pending Legal Charges?:Yes   No              

Adjudicated:Yes   No      

Third Party Coverage: ____________________________________

* Medicaid Number: ___________________________Medicare Number:

InsuranceType:_____________________Policy Holder/ID No./Grp No: _____________ ___________

Other (IPRS,JCPC, Federal Probation, Etc.)_____________________________________

Brief Narrative:*  __________________________________________________________________

  ________________________________________________________________________________

_________________________________________________________________________________

Please allow 24 hours response time to your referral and 10 working days for an appointment with SAIS Treatment Program. 

FOR SAIS OFFICE USE ONLY:

The following determination of the above referral was made:    

Date Referral Rcv'd: __________________________   Date Replied To:  ______________

Service Accepted ?Time:_______________________ Date: _________________

Initial Cost (if applic): ___________   Other ?Mailing address: ________________________________