MA Outpatient Med Management Referral Form

MA Outpatient Therapy Referral Form

Including Medication Management
Outpatient Therapy:

Individual Counseling for adults and youth ages 5+ (with parent or guardian assistance) that provides long term, non-acute mental and behavioral health concerns provided via telehealth. Telehealth services for Outpatient Therapy is available.
Medication Management:

Medication Management for clients 12 years and older.
Today's Date:*

MonthDayYear
Date
Client's Legal Name:*

First NameLast Name
Client's Affirmed Name:*
Client's Date of Birth:*

MonthDayYear
Date
Client's Social Security Number:
Client's Gender Identity:*

Man or Boy (Cis)Woman or Girl (Cis)Transgender Man or Boy/Trans Man/MasculineTransgender Woman or Girl/Trans Woman/FeminineGenderqueer/Gender Expansive/Nonbinary/Neither exclusively male nor female
Would client be interested in the Pride Team for Outpatient Services. Our inclusive PRIDE Team consists of highly qualified mental health professionals and paraprofessionals who are a part of the LGBTQIA+ community. Our PRIDE Team is thoughtful in our choice of respectful language, behaviors, and continued education to best reflect the current needs and expectations of the LGBTQIA+ community."*

YesNo
How did you hear about us?
Location Preference:*

In PersonTelehealth
If Interested in In-Person Services Which Office Locations Work Best For You?

Fall River, MANorth Andover, MADorchester, MAWest Springfield, MAWorcester, MA
Scheduling Preference (Day and Time of Day); Telehealth Services may be Available:*

MondayTuesdayWednesdayThursdayFridaySaturdayMorningsAfternoonsEarly EveningsEvenings (By Appointment Only)
Language Needed for Service:*
Do you have an Outpatient Therapist gender preference?*

WomanManTrans/Genderqueer/Non-binaryNo Preference
Would you be willing to be assigned to an Outpatient Intern?*

YesNo
Do you have a preferred Therapist/Clinician you would like to see? Please provide their name:
Guardian Name:

First NameLast Name
Client/Guardian Address:*

Street Address

Street Address Line 2

City

Zip Code
Client/Guardian Phone Number:*
Please enter a valid phone number.
Client/Guardian Email:*
example@example.com
Guardian's Preferred Language:
Need for Medication Management Services*

YesNo
If Yes, Please Explain:
Medication Management Only:*

YesNo
Insurance ID:*
Primary Insurance Type:*

MassHealth - Massachusetts Behavioral Health Partnership (MBHP)MassHealth - BeHealthy Partnership (MA MBHP Health New England)MassHealth - Beacon BMC Healthnet Plan Southcoast AllianceMassHealth - Beacon BMCHP QHP ConnectorCare Plan 1, 2 and 3MassHealth - Beacon Fallon 365 CareMassHealth - Beacon Wellforce Care Plan / WellsenseMassHealth - Tufts Health Direct ConnectorCare IMassHealth - Optum My Care Family (MA Allways Health Partners MCD)Commercial - Blue Cross Blue Shield of MACommercial - Blue Cross Blue Shield AnthemCommercial - Harvard Pilgrim (United Behavioral Health)Commercial - Optum United Health CareCommercial - Optum Allways Health PartnersCommercial - TuftsCommercial - Fallon Health CareCommercial - Blue Cross Blue Shield Federal
If able please upload a picture of the front and back of your insurance card

Cancelof
Insurance Policy Holder Name:

First NameLast Name
Insurance Policy Holder Date of Birth:

MonthDayYear
Date
Insurance Policy Holder Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Policy Holder Cell Number:
Please enter a valid phone number.
Insurance Policy Holder Home Number:
Please enter a valid phone number.
Insurance Policy Holder Work Number:
Please enter a valid phone number.
Referred By:

First NameLast Name
Referent Phone Number:
Please enter a valid phone number.
Referent Agency:
Referent Email:
example@example.com
Presenting Problem/Issue:*
Diagnosis:*
How did you hear about Northeast Family Services*

NFS WebsiteFriend or FamilyReferred by another agencyOther
MH Providers: please attach clinical assessment(s), recent CANS, current treatment plan
Should be Empty:

MA Outpatient Therapy Referral Form