Psychiatry Services Referral Form

Northeast Family Services

Psyhiatry Services

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: *
Our center does not provide treatment for alcohol and/or substance abuse. Please have the patient contact thier insurance company for available treatment options for these disorders.
What is the client's chief complaint? Please Describe: *
Choose Severity of the Problem: *

MILD MODERATE SEVERE (Hospitalizations or crisis evaluation)
Describe: *
What is the key question you want addressed? *
Diagnosis (DSM V) if known:
Primary Care Physician: *
Primary Care Physician Phone Number: *

Area Code Phone Number
Allergies:
Relevant Medical Information:
Present Medications:
Past Medications:
Current Therapist Name/Credentials: *
Current Therapist Phone Number: *

Area Code Phone Number
Current Therapist Title: *
Current Therapist Agency/Affiliation: *
Other Information:
Upload anyadditional documents or forms to be submitted here:
For any additional documents or forms to be submitted

Fax or mail to:

354 Merrimack St Suite 395

Lawrence, MA 01843

Fax: (774) 628-9657
Should be Empty: