Outpatient Therapy/Psychology Med Management Referral Form - Rhode Island
Date of Referral:
*
-
Month
-
Day
Year
Date
Client's Legal Name:
*
First Name
Last Name
Known As:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender Identity:
*
Female
Male
Transgender
Non-binary
Other
Email:
*
example@example.com
Social Security Number:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian Name:
First Name
Last Name
Client/Guardian Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client would prefer to receive services:
*
In-Person
Via Telehealth (Virtually)
Both (In-Person and Via Telehealth)
If Both, Please Explain:
Need for Medication Management Services
*
Yes
No
If Yes, Please Explain:
Outpatient Therapy:
*
Yes
No
Medication Management Only:
*
Yes
No
Substance Use Services (Outpatient)
Yes
No
Insurance ID:
*
Primary Insurance Type:
*
Blue Cross Blue Shield
Neighborhood Health Plan
United Behavioral Health
Tufts Health Plan
Other
For Above Enter Other information and/or which BCBS State (i.e. BCBSRI, BCBSMA, etc.):
Policy Holder:
First Name
Last Name
Policy Holder Date of Birth:
-
Month
-
Day
Year
Date
Policy Holder Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Holder Cell Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Policy Holder Home Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Policy Holder Work Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Insurance ID:
Secondary Insurance Type:
Blue Cross Blue Shield
Neighborhood Health Plan
United Behavioral Health
Tufts Health Plan
Other
For Above Enter Other information and/or which BCBS State (i.e. BCBSRI, BCBSMA, etc.):
Policy Holder:
First Name
Last Name
Policy Holder Date of Birth:
-
Month
-
Day
Year
Date
Policy Holder Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Holder Cell Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Policy Holder Home Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Policy Holder Work Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Source:
Direct Mail
Website Search
Psychology Today
Magazine Ad
Social Media
Word of Mouth
Court System
Employer/ Employee Assistance Program
Federal or State Social Services Agency
Hospital Emergency Room
Mental Health Care Provider
Health Care Provider
School System
Self
Shelter
Substance Use Treatment Provider
Zencare
Referred By:
First Name
Last Name
Referent Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Referent Agency:
Referent Email:
example@example.com
Presenting Problem/Issue:
*
Schedule Preference:
Monday
Tuesday
Wednesday
Thursday
Friday
Schedule Preference:
Morning
Afternoon
Evening
Please list any specific scheduling preferences:
*
Therapist Gender Preference:
Male
Female
No preference
Preferred Clinician's Name:
MH Providers: please attach clinical assessment(s), recent CANS, current treatment plan
How did you hear about Northeast Family Services?
*
NFS Website
Friend or Family
Referred by another agency
Other
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