Referral Form

Apply for services from Plains Area Mental Health Center with our convenient online form. Our team will contact you as soon as possible with the next steps.

    Referral Source Information

  1. Patient Information

  2. Please complete this section if the patient is living at a different location than their legal address.
  3. Parent/Legal Guardian Information

    This section should be completed if the patient is a minor or adult under legal guardianship.

  4. Insurance Information

  5. Iowa Total Care
    Iowa Medicaid Enterprise (IME)
    Other Insurance
  6. Diagnosis Information

  7. Please list ICD-10 codes.
  8. Please list ICD-10 codes.
  9. Please include credentials.
  10. Other Information

  11. What services provided by Plains Area Mental Health Center are being requested for the patient?
  12. Examples: Iowa Vocational Rehabilitation Services, Mental Health & Disability Services Region, Juvenile Court Officer, therapy, payee, etc.