CPR WEBSITE FORMS- UPDATED

WELCOME TO CPR
Dear prospective client,

CPR offers a wide variety of services to support different needs. Below is an explanation of our services to better help you decide what type of referral/s to submit.

PUBLIC SAFETY: CPR's Public Safety Department serves first responders and their immediate family members with medication management, counseling, wellness checks, and other state of the art services. If you are an active or retired first responder (e.g. Police Officers, Fire Fighters, EMTs, Correction Officers) or an immediate family member (e.g. spouse, child) of a first responder, please follow the PUBLIC SAFETY TRACK.

OUTPATIENT SERVICES: Outpatient services are offered to the public at large. They include medication management, counseling services, and case management. There are some constrains on these services based on age and insurance type. Your eligibility for these services will be established before you have to enter any personal information.

ROUTINE SMI EVALUATIONS: The SMI Program is a state funded program that offers psychiatric treatment, medication management, and case management to any individual that meets criteria for the program. To request a routine SMI Evaluation please call (480)804-9542 Monday through Friday during business hours.

HOSPITAL/JAIL/PRISON SMI EVALUATIONS: Only hospitals, jails, or prisons can submit referrals for these types of evaluations. Hospital evaluations (urgent) are typically completed within 24 hours of the referral, jail evaluations within 7 business days, and prison evaluations within 30 days.

CRISIS RAPID RESPONSE: CPR’s crisis department completes interventions at many hospital EDs and floors in Maricopa and Pinal counties. Only hospitals and PCP offices currently contracted with CPR are able to request Crisis Rapid Response services.
What type of referral are you making today?*

Public SafetyOutpatient ServicesHospital/Jail/Prison SMI EvaluationCrisis Rapid Response

PUBLIC SAFETY REFERRAL
Are you making a referral for yourself or someone else*

MyselfSomeone else
Public Safety Status:*

Active or Retired First ResponderImmediate Family Member of First Responder
Family Member of first responder*

Spouse/ Significant OtherChildSiblingParentNone of the above
Please consider following the Outpatient Services track. It does not appear you qualify for Public Safety services.
Public Safety Agency
If other, indicate agency:*

PUBLIC SAFETY
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Insurance Card Upload (optional)

Cancelof
ID (optional)

Cancelof

OUTPATIENT SERVICES REFERRAL
Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Biological Sex*

MaleFemaleOther
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Insurance Card (please scan front and back) (optional)

Cancelof
ID (optional)

Cancelof

RAPID RESPONSE CRISIS REFERRAL
Facility*
Referral Type:*

ERFloor (inpatient)ObservationCommunity
Facility Contact (Name and Phone number)*
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Biological Sex*

MaleFemaleOther
Medical Record Number (MRN) #
Title19*

YesNo
AHCCCS ID (if applicable)
Please attach any necessary medical records

Cancelof

EXTENDED EVALUATIONS PROGRAM REFERRALS
Referral Date and Time
Client Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Client Phone Number*
Please enter a valid phone number.
Client Email
example@example.com
Is the client T19?*

YesNo
AHCCCS ID*
AHCCCS (Medicaid) Insurance
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pend Date*

MonthDayYear
Date
Summary Outcome Date*

MonthDayYear
Date
SMI Determination Due Date*

MonthDayYear
Date
Please upload any documents relevant to the referral

Cancelof

WELCOME TO CPR

PUBLIC SAFETY REFERRAL

Please consider following the Outpatient Services track. It does not appear you qualify for Public Safety services.

PUBLIC SAFETY

OUTPATIENT SERVICES REFERRAL

We apologize, CPR does not currently have contracted AHCCCS providers for minors. However, here is a list of alternative providers that may be able to meet your needs:

OUTPATIENT SERVICES REFERRAL

HOSPITAL/JAIL/PRISON SMI EVALUATION REFERRAL

RAPID RESPONSE CRISIS REFERRAL

EXTENDED EVALUATIONS PROGRAM REFERRALS

PHOENIX PD REFERRAL FORM

RURAL METRO FIRE AND MEDICAL REFERRAL FORM

GILBERT FIRE RESCUE REFERRAL FORM