Outpatient Therapy/Psychiatry 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.
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:
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.
Policy Holder Home Number:
Please enter a valid phone number.
Policy Holder Work Number:
Please enter a valid phone number.
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.
Policy Holder Home Number:
Please enter a valid phone number.
Policy Holder Work Number:
Please enter a valid phone number.
Referred By:
First Name
Last Name
Referent Phone Number:
Please enter a valid phone number.
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
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