Autism Treatment Services Referral Form

Northeast Family Services

Autism Treatment Services Referral Form

Please complete all sections

Note that incomplete information may delay service delivery
Date of Referral: *

Month Day Year
Date
Client Name: *

First Name Last Name
Sex: *

Female Male
DOB: *

Month Day Year
Date
SSN: *
Primary Insurance Type: *

MBHP UBH BCBS Tufts Harvard Pilgrim
Insurance ID: *
Policy Holder: *

First Name Last Name
Policy Holder DOB: *

Month Day Year
Date
Referral Source Name/Credentials: *
Referral Source Phone Number: *

Area Code Phone Number
Referral Source Title: *
Referral Source Agency/Affiliation: *
Insurance Care Advocate/Case Manager: *

First Name Last Name
Insurance Care Advocate/Case Manager Phone Number: *

Area Code Phone Number
Primary Contact: *

First Name Last Name
Relationship to Client: *
Legal Guardian? *

Yes No
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number:

Area Code Phone Number
Cell Phone Number:

Area Code Phone Number
Work Phone Number:

Area Code Phone Number
Presenting Issue/History: *
Diagnosis (DSM IV): Please include diagnostic evaluation completed by a licensed physician or licensed psychologist. *
Primary Care Physician: *
Primary Care Physician Phone Number: *

Area Code Phone Number
Allergies:
Relevant Medical Information:
Medications:
Psychiatrist: *
Psychiatrist Phone Number: *

Area Code Phone Number
School Information (name, location, grade, special education/current IEP, academic/social performance, behaviors): *
Other Information:
Upload anyadditional documents or forms to be submitted here:
To complete referral:
Fax or mail this form and any attachments to:

Northeast Family Services
354 Merrimack St Suite 395
Lawrence, MA 01843
Fax: (774) 628-9657