Patient Referral Form

Adult Intensive Outpatient Program (IOP) · TJC-Accredited
6404 International Parkway, Suite 1010, Plano, TX 75093

This is not an emergency service. If someone is in immediate danger or crisis, call 911, or call or text 988 (Suicide & Crisis Lifeline).

Referral urgency Routine Urgent

Same-day / next-business-day intake available. Referral response within 4 business hours.

Patient information Patient full name required Date of birth required Phone Email Preferred contact method / best time Address (street, city, state, ZIP) OK to leave voicemail Patient is aware of this referral

Insurance information Insurance carrier / plan Member ID Group # Subscriber name (if not patient) Subscriber date of birth Insurance phone (back of card)

Reason for referral Primary diagnosis / presenting concerns required Current medications (if known) Additional clinical notes: recent hospitalization, safety concerns, treatment history, goals for IOP

Referring provider / practice Provider name & credentials required Practice / organization required Contact person for this referral Phone phone or email required Fax Email Date of referral Completed by (name & role) Ascent BD representative (if assisted)

What happens next: our team responds to every referral within 4 business hours. Intake is typically scheduled same-day or next business day, and we provide outcomes communication back to your office from admission through discharge.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Referral received