Registration

Behavioral Health Navigators Center, Inc.

info@behavioral-health-navigators.org
             www.behavioral-health-navigators.org       

(877) 532-5571 Office
(877) 241-1004 Fax


                                                                          
                                                                            
WELCOME:

Referring Agency: ___________________________________________________________________

Participant's Name: __________________________________________________________________

Phone:(work)____________________(cell phone)__________________________________________

Email:(personal, Caseworker, or relative) _________________________________________________
 

Home address: City:_______________________________State:______________________________

 

Are you a client of a Core Service Agency? Yes or No

Primary Care Physician: _________________Phone:________________________________________

Psychiatrist: ___________________________Phone:________________________________________

Psychologist: __________________________Phone:________________________________________

 

Name of Caseworker:____________________Phone:________________________________________

Do you authorize permission for an exchange of health information with  BHNC?   Yes or No

Name: ______________________________ Signature: ______________________________________
Expiration: (365) days or upon notice 
 

 Please circle area of interest:

  • Outpatient Mental Health Clinic (OMHC)
  • Adult Rehabilitation Program (PRP)
  • Adult Medical Day Services
  • Navigation Support Services
  • Psychiatric Rehabilitation Program
  • Assisted Living
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    "It does not matter how slowly you go up, so long as you don't stop."

    -- Confucius, Philosopher