Foundation
Research
Careers
Banyan Health Systems
Appointments: 1-855-922-6926
24 Hour Crisis Hotline:
Book an Appointment
Locations
Donate Now
Search
About
Our History
Our Locations
Executive Leadership
BCHC Board of Directors
Ways to Give
News
Community Health
Pharmacy
Primary Care Services
Pediatrics
Adolescent Health
Women’s Health
Maternal Health
Laboratory Services
Adult Psychiatric Services
Pediatric Psychiatric Services
Substance Abuse
Concept Health
24 Hour Programs
Residential Behavioral Health Centers
Crisis Stabilization Unit & Recovery Center (CSU)
Centralized Receiving Facility
Specialty Programs
Sliding Fee Discount Program
Telehealth
Banyan Works
HIV Prevention Program
Foundation & Research
Foundation
Foundation Board of Directors
Research
Community Partners and Resources
Ways to Give
Referrals
Patient Referrals for Agencies
Patient Referrals for Parents
Contact
Locations
About
Our History
Our Locations
Executive Leadership
News
Ways to Give
Community Health
Pharmacy
Primary Care Services
Pediatrics
Adolescent Health
Women’s Health
Obstetrics & Gynecology(OBGYN)
Behavioral
Adult Psychiatric Services
Pediatric Psychiatric Services
Residential Behavioral Health Centers
Substance Abuse
Crisis Stabilization Unit & Recovery Center (CSU)
Centralized Receiving Facility
Concept Health
Concept Health Board of Directors
Specialty Programs
Banyan Works
Sliding Fee Discount Program
Foundation & Research
Foundation
Board of Directors
Board Members
Foundation Board of Directors
Research
BRIC Board of Directors
Community Partners and Resources
Ways to Give
Patient Information
Patient Referrals for Agencies
Patient Referrals for Parents
Contact Us
Our Locations
Close Nav
About
Our History
Our Locations
Executive Leadership
News
Ways to Give
Community Health
Pharmacy
Primary Care Services
Pediatrics
Adolescent Health
Women’s Health
Obstetrics & Gynecology(OBGYN)
Behavioral
Adult Psychiatric Services
Pediatric Psychiatric Services
Residential Behavioral Health Centers
Substance Abuse
Crisis Stabilization Unit & Recovery Center (CSU)
Centralized Receiving Facility
Concept Health
Concept Health Board of Directors
Specialty Programs
Banyan Works
Sliding Fee Discount Program
Foundation & Research
Foundation
Board of Directors
Board Members
Foundation Board of Directors
Research
BRIC Board of Directors
Community Partners and Resources
Ways to Give
Patient Information
Patient Referrals for Agencies
Patient Referrals for Parents
Contact Us
Our Locations
Patient Referral Form
Referrers Information
Name
*
Organization
*
Phone
Email
*
Relationship to Patient Being Referred
*
Patient Information
Full Name
*
Phone
Date of Birth
Street Address
*
City
*
Zip
*
Preferred Language for Assessment
Preferred Language for Services
Please attach the Consent to Release or Obtain Protected Health Information:
Max. file size: 50 MB.
Has a Consent to Release or Obtain Protected Health Information been attached to referral?
*
Yes
No
If applicable, please attach the discharge plan:
Max. file size: 50 MB.
Is this referral made to support a discharge plan?
*
Yes
No
If yes, has a copy been provided?
*
Yes
No
If patient is a minor, please fill out the following section:
Parent or Guardian Full Name
Phone
Name of School
Grade Level
Reason for Referral
(Check all that apply & include additional concerns below)
Reason For Referral
*
Mental Health
Substance Abuse
Primary Care
Court Order (please attach)
If applicable, please attach court order:
Max. file size: 50 MB.
Program/Service Requested
Program / Service Requested
*
Counseling
Case Management
Medication-Assisted Treatment
Psychiatry
Resident Level II
Don't Know
Other
If other, please describe:
Patient Insurance Information
Does the patient have insurance?
*
Yes
No
Insurance Company
Policy Number
Member ID
Preferred Location for Service of Patient
Preferred Location for Service of Patient
Banyan Community Health Center
Lauderdale Lakes
4900 West Oakland Park Blvd.
Lauderdale Lakes, FL 33313
Banyan Community Health Center
Flagler Family Clinic
3733 W Flagler Street,
Miami, FL 33134
Banyan Community Health Center
Little Havana Campus
3850 W Flagler Street,
Miami, FL 33134
Banyan Community Health Center
Cutler Bay
10720 Caribbean Blvd., Suite 420
Culter Bay, FL 33189
For referral questions please call:
305-900-4817
