Military Services Referral Form I am referring someone else Step 1 of 4 25% CompanyThis field is for validation purposes and should be left unchanged. This form is only monitored Monday - Friday during regular business hours (9:00am – 5:00pm CST). If you or a loved one are experiencing a mental health emergency, please contact one of our crisis lines or dial 911. Referral Representative InformationReferral Representative Name(Required) First Last This field is hidden when viewing the formOrganization(Required)Referring Partner(Required)Please Select Referring PartnerCenterstoneCohen ClinicElizabeth Dole FoundationFBIFirst Responder’s Children’s FoundationLone Soldier CVNMilitary One SourceNational GuardSelf-ReferralStop Soldier SuicideTAPSUniversityUnknownUS VetsVeterans Wellness AllianceWarrior Care NetworkWounded Warrior ProjectOtherReferring Partner: Other(Required)Referral Representative Email(Required) Is client aware of referral to Centerstone Military Services?(Required)Select Yes / NoYesNo Client Referral InformationIf referral request is for a minor, please list the phone and email for parent/guardian Military Status:(Required)Select StatusActive DutyReservesNational GuardVeteranFamily Member or CaregiverBranch of Service:(Required)Select BranchArmyAir ForceMarine CorpsNavyCoast GuardSpace ForceEra of Service:(Required)Select EraPre 9/11Post 9/11Service Member/Veteran’s Name:(Required) First Last Client’s Relation to Service Member/Veteran:(Required)Spouse / PartnerCaregiverChildOtherClient’s Relation to Service Member/Veteran: Other:(Required) Client Name:(Required) First Last Parent/Guardian Name:(Required) First Last Child's Name:(Required) First Last Client Date of Birth(Required) MM slash DD slash YYYY Child's Date of Birth(Required) MM slash DD slash YYYY Email Address(Required) Enter Email Confirm Email Does the client currently have insurance? If so, please select your insurance provider:(Required)CommercialMedicaidMedicareEAPWorker’s Comp.UninsuredUnknownWhere does the client live?(Required) United States International Phone Number(Required)Phone Number(International)(Required)Client’s Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Client’s Address (International)(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Presenting Issues:Current Barriers to Care (Transportation, Financial, etc.):Does client have insurance coverage*? Yes No *For informational purposes only; info NOT used to determine eligibility If yes, please specify carrier:Is this condition related to military service? Yes No Is this condition considered a LOD determination? Yes No Type of Counseling Requested: Individual Couples Family Preferred Service Delivery (In-Person / Telehealth)No preferenceTelehealthIn-personName of preferred care coordinator at Centerstone you’d like this referral to be directed to?*Optional
