Make A Referral

Professionals who make referrals to Portage Path Behavioral Health, such as physicians, counselors, social workers, law enforcement/legal professionals, and social service employees are able to use this feature to begin the process of making a referral to portage Path Behavioral Health.

The only information we are able to provide you with about your patient's / client's treatment at Portage Path is whether or not they showed up for their first (Intake) appointment. You will receive a response in the mail with this information.

If you think you will require ANY additional information about your patient / client, please take a moment now to download a copy of our Release of Information form.

Also, please know that experience has shown us that frequently individuals do not follow through with the referral made by a professional like yourself. You can help make sure your patient / client gets the help they need by reinforcing the importance of making and keeping their appointment, and by reminding them that you will know whether or not they made / kept the appointment.

To make a referral, just fill in the fields below, and a Portage Path admissions specialist will call your client to obtain more information and schedule an Intake appointment.

If you would prefer to fill out this form on paper and fax it to us, please dowload the PDF version. Otherwise, proceed to the questions below.

Please provide us with the following information to get started with the referral process.

Please fill all * fields.

About The Referral Source



About The Patient


Male Female
Aetna
Anthem
Buckeye Community Health Plan
Caresource
Gateway Healthcare
Humana
Magellan Networks
Medical Mutual of Ohio
Medicare Part B
Medicaid (all plans)
Molina Healthcare
Paramount
Tricare
United Healthcare/United Behavioral Health
Wellcare
Self Pay (no insurance)
Depression
Anxiety
Mood Swings
PTSD
Psychosis
Eating Disorder
Anger
OCD
Marital/Relationship
Legal
Housing
Financial
Aggression

Yes No
Yes No
Inpatient
Outpatient
Substance
Past CSS client
Past Portage Path client
none
Psychiatric
Med./Somatic
Individual Psychotherapy
Group Treatment
Brief Treatment
Anger Management
Coping Skills/DBT
Dual Diagnosis/SAMI
Sex Offender Treatment
Partial Hospitalization
Release form completed and mailed
Release pending
No release

Please Note: To download our Release of Information Form, and to view instructions for completing the release, please visit our Releases of Information page after finishing this form.


About Your Confidentiality