Referral For Veteran Crisis Services Referral Source InformationREFERRAL SOURCE NAME(Required)REFERRAL SOURCE ORGANIZATIONREFERRAL SOURCE PHONE(Required)REFERRAL SOURCE EMAIL Client InformationCLIENT FIRST NAME(Required)CLIENT LAST NAME(Required)CLIENT AGECLIENT DOB MM slash DD slash YYYY CLIENT SSN (optional)CLIENT PHONE(Required)CLIENT EMAIL(Required) REASON FOR REFERRAL (check all that apply)(Required) The client recently experienced a life-threatening mental health crisis or attempted suicide The client is on a waiting list for long-term therapy and is at risk of severe functional decline or adverse outcomes while waiting. The client is currently in therapy but could benefit from a short course of crisis-specific treatment, suicide-specific treatment, interim counseling, skills training, or resiliency coaching. The client is being discharged from inpatient care or long-term therapy and would benefit from therapeutic intervention to mitigate the risk of decline and readmission. The client is a survivor of suicide loss. Other Please explain other reason for the referral:CLIENT INSURANCE (Check All That Apply) Medicaid Medicare Blue Cross & Blue Shield Presbyterian Health Plan United Healthcare TriWest/ChampVA (Military Insurance) Unknown Other OTHER INSURANCE NAMEIS THE INDIVIDUAL AN ACTIVE-DUTY SERVICE MEMBER, VETERAN, OR A MILITARY FAMILY MEMBER?(Required) YES NO DID THE CLIENT CONSENT TO THIS REFERRAL?(Required) YES NO ADDITIONAL NOTES (OPTIONAL)Confirmation of UnderstandingThis referral form is part of an automated system that is not monitored around the clock. Your request will required up to 48 business hours to process. If this is an acute suicidal crisis or need to speak to someone immediately, please contact 988 Suicide Hotline, the New Mexico Crisis Line, or 911 Emergency Services. Confirmation(Required) I understand.