Refer – MAZWI HOLISTIC INSTITUTE

ABOUT MAZWI HOLISTIC INSTITUTE

Client Referral Form

Confidential Referral Submission

Thank you for referring an individual to Mazwi Holistic Institute (MHI). We are committed to providing compassionate, individualized behavioral health and substance use treatment services. Please complete the following information to assist our intake team in reviewing and coordinating the referral. Fields marked with an asterisk (*) are required.

Section 1: Referring Party Information

Referral Source / Organization Name

Name of Referring Individual

Title / Position

Phone Number

Email Address

Preferred Method of Contact

Phone Email

Referral Source Type

Section 2: Client Information

Client Full Legal Name

Date of Birth

Phone Number

Email Address

Preferred Method of Contact

Phone Email Other

If Other, please specify

Is it safe to leave a voicemail?

Yes No Unknown

City / State of Residence

Preferred Language

Is the client aware of this referral?

Yes No Unknown

Section 3: Services Requested

Please select the service(s) for which the individual is being referred

Service availability, clinical appropriateness, and eligibility will be determined by MHI’s intake and clinical teams.

Section 4: Insurance Information

Insurance Coverage

Insurance Provider / Managed Care Organization

Insurance Member ID

Insurance information may be verified directly with the client during intake. Submission does not guarantee coverage or authorization

Section 5: Referral Details

Primary Reason for Referral

Preferred Intake Timeline

Soon As Possible Within 1–3 Business Days Within One Week Flexible

Additional Information / Coordination Needs

Please do not include detailed clinical records, Social Security numbers, or other unnecessary sensitive information

Section 6: Supporting Documentation

Do you have supporting referral documentation?

Yes No

Supporting clinical documents should be transmitted only through an MHI-approved secure method. Our intake team will contact you with instructions.

Section 7: Referral Acknowledgment

I confirm that the information submitted is accurate to the best of my knowledge.

I understand that submitting this form does not guarantee admission, eligibility, or acceptance into services.

I understand that MHI may contact the prospective client to discuss services and intake.

Referrer Name

Date of Submission

ABOUT MAZWI HOLISTIC INSTITUTE

Client Referral Form

Confidential Referral Submission

Section 1: Referring Party Information

Section 2: Client Information

Section 3: Services Requested

Section 4: Insurance Information

Section 5: Referral Details

Section 6: Supporting Documentation

Section 7: Referral Acknowledgment

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Mazwi Holistic Institute is a 501(c)(3) and all donations are tax deductible.
EIN 84-3874429

Office Hours

Monday – Friday - 10AM - 6PM
Saturday – by Appointment

Quick Links

Services

CONTACT INFO

Licensed in Maryland by the Maryland’s Behavioral Health Administration

Copyright © 2024 with Mazwi Holistic Institute, INC

Leave Your Details For More Information

drop us a line

ABOUT MAZWI HOLISTIC INSTITUTE

Client Referral Form

Confidential Referral Submission

Section 1: Referring Party Information

Section 2: Client Information

Section 3: Services Requested

Section 4: Insurance Information

Section 5: Referral Details

Section 6: Supporting Documentation

Section 7: Referral Acknowledgment

Subscribe to Our Email List

Mazwi Holistic Institute is a 501(c)(3) and all donations are tax deductible. EIN 84-3874429

Office Hours

Monday – Friday - 10AM - 6PMSaturday – by Appointment

Quick Links

Services

CONTACT INFO

Licensed in Maryland by the Maryland’s Behavioral Health Administration

Copyright © 2024 with Mazwi Holistic Institute, INC

Leave Your Details For More Information

drop us a line

Mazwi Holistic Institute is a 501(c)(3) and all donations are tax deductible.
EIN 84-3874429

Monday – Friday - 10AM - 6PM
Saturday – by Appointment