ARMHS REFERRALPlease fill out the following key information needed to assess eligibility and begin services. Referral Name Referral Type Case Manager Physician Mental Health Provider Self Other Referral Phone Number (###) ### #### Referral Email Client Info First Name Last Name Client Phone Number (###) ### #### Client Email Address Date of Birth County of Residence Insurance Type Diagnosis Depressive Disorder Post-Traumatic Stress Disorder Bipolar Anxiety Schizophrenia Substance Abuse Disorder Other Has had a diagnostic assessment within the past 12 months recommending ARMHS? Yes No Additional Comments Thank you! Someone from our team will be in touch with you shortly.