Client Self Referral Form
To be completed by clients ages 18 and older or Legal Guardians for clients they have guardianship or legal custody of for telehealth therapy in Massachusetts. We will contact you as soon as we can for a consultation within the next few weeks to see if we are a good match for therapy. ***If you are in crisis and need to be seen immediately, please contact your local Crisis Office or you can contact the BHHL 24 hours a day, 7 days a week, 365 days a year – including holidays at 1-833-773-2445. We do not schedule emergency appointments and do not respond to crisis situations.
Name of client you are referring
First Name
Last Name
Information about Person Completing Referral
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to person you are referring:
*
Is client being referred and previous client? If yes, please list approximately when client was with us before
Are you requesting a specific clinician or have specific preference. (Please note, we cannot guarantee specific client can be assigned but will attempt to assist with the request. If we are not able to assist with the request and have identified client needs to seek a clinician that meet specific needs, we will give clients additional resource for them to refer to.)
How did you hear about us and the services we provide or who referred you to us? If you were referred by Therapy Matcher, please list they referred you and what clinician they referred you to see
*
Is Client being referred under age of 18 or has a Legal Guardian with conservatorship?
*
Client is under age 18
Client is over 18
Client is over age 18 and has a Legal Guardian/Conservator
If we currently do not have availability for new clients, is the client/Guardian wanting to inquire about being on a waitlist during initial consult?
*
Yes
No
Days and Times Client is available for In-Person or Telehealth Therapy: (Please note, In-Person sessions are scheduled during business hours of Mon-Fri 8am-5pm and closed most major Holidays.)
*
*
If Client is under age 18 or has Guardian please complete the following information
Guardians Name
First Name
Last Name
Guaridans Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
If client is a Minor, please list second parents name, address, phone number and if they have shared legal or physical custody.
If client is a minor, who is the main subscriber of insurance? Please list insurance subscribers name, address, phone and date of birth.
Please upload current copy of Guardianship, MITS & Release (if DCF Guardianship), legal Custody Paperwork (if client is a minor and parents are seperated or divorced) and any other documents needed.
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Client's Individual Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Primary Health Insurance
*
Insurance Number
*
Name of Secondary Health Insurance
Secondary Insurance Number
Please upload copy of both sides of Clients Insurance Card (s). If you do not have a copy, please obtain from your insurance a electronic version and upload it below.
*
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Please upload copy of both sides of your Photo ID if you are referring yourself and are 18 years or older. We are required to verify clients ID's match their insurance cards for billing requirements.
*
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Is Individual aware of this Referral?
*
Yes
No
Telehealth or In Person Therapy Program referring for:
*
Child/Adolescent(ages 10-18)Individual Outpatient Therapy
Adult Individual (ages 18 and up) Outpatient Therapy
Child/Adolescent (ages 10-18) Group Therapy
Adult (ages 18 and up) Group Therapy
Other
Are you referring for
*
In-Person Sessions at our Pittsfield, MA location
Avaiolable for both In-Person and Telehealth Sessions
Telehealth Session
If In-Persons sessions are not available and want In-Person sessions, are you able to meet via telehealth until a spot can open up for In-Person?
Yes
No
Individual Gender
*
Male
Female
Other
Individual Primary Language
*
English
Spanish
Other
Current Medications
*
Please list the name, address and phone number of your Doctor (PCP)
*
Reason for Referral
*
Select all applicable challenges below for the Individual referred (check all that apply)
*
Ability to avoid dangers/hazards
Anger
Anxiety
Community Linkage of Services
Daily living skills
Depression
Grief
Housing
Hygiene
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Maintaining personal affairs
Medication Education
Nutritional
Phobia/s
PRTF/Hospital Discharge
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Sustainable employment
Trauma
Truancy
Whole Health/Wellness
Youth to Young Adult Transition
Other (please list in section above in "Reason for Referral"
If we are not able to reach you (if referring your self or your minor child you have guardianship of), can we reach out to you by email to schedule consultation and or appointments?
*
Yes, please connect with me by email to schedule a consult and or appointments if unable to reach me by phone.
Yes, you can reach out to me both by email and phone to schedule a consult and or appointments.
No, please only reach out to me by phone.
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