New York Outpatient Referral Form

Outpatient Therapy Referral Form
Client Name*
Date*

MonthDayYear
Date
Sex*

MF
DOB*
SSN*
Client's Preferred Language:*
Primary Insurance Type*
Insurance ID*
Policy Holder*
Policy Holder DOB*
Insurance Card Upload: If able, please upload a picture of the front and back of your insurance card(s).

Cancelof
Address*
Home #*
Cell #*
Work #*
Email:*
example@example.com
Referred by (if applicable)
Phone
Reason for Referral/Goals: (symptoms, ,behavioral/social/emotional functioning of youth/family, focus of treatment)*
Family's Preference for Scheduling:*

SundayMondayTuesdayWednesdayThursdayFridaySaturdayMorningsAfternoonsEarly EveningsEvenings
Family's Preference for Service Location

In PersonTelehealth
Times*
General Mental Health Coverage:
Copay*
Deductible*
Authorization Required?*

YesNo
Additional lnformation*
Verified by
Date

MonthDayYear
Date
Insurance Representative
Phone #
Email*
example@example.com
Preferred Method of Communication

Phone CallText MessageEmailOther
How did you hear about Northeast Family Services?*

NFS WebsiteFriend or FamilyReferred by another agencyOther
Should be Empty:

Outpatient Therapy Referral Form