Confianza Healthcare New Referral Referring Agency Information arrowup6 Agency Name Referring Provider Name Date Phone Fax Relationship to Member Member Information arrowup6 Name Name First First Last Last Date of Birth AHCCCS ID# Health Insurance Name Phone Email Gender Male Female They/Them OtherOther Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Guardian Information arrowup6 Guardian Name Guardian Name First First Last Last Phone Email Custody Agreement YesNoOther Custody Agreement Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Reason for Referral arrowup6 Reason for Referral Diagnosis if known Relevant Social Factors History of Violence Yes No OtherOther History of Suicide Attempts Yes No OtherOther History of Psychiatric Hospitalization Yes No OtherOther Current Symptoms Additional Information If you are human, leave this field blank. Submit SERVICESPersonalized Care and Guidance Therapeutic ServicesCompassionate Families deserve to be happy. Confianza Health helps families reconnect with one another in a meaningful way. life Skills GroupsHere For You Behavioral Coaching helps children and adolescents learn how to function in a positive and effective way nurturing ParentQuality Care Confianza Health basis all therapies on the Trauma Informed approach. This allows individuals and families to address very difficult emotional concerns in a caring and compassionate way. Family SupportResults Parent Support Navigate Services Parenting Techniques Parent Education