Referral Form
For Patients & Providers. Please note, that we do not see children under the age of 9 years old in MA and under the age of 6 years old in California
Will this appointment be for you or are you making a referral for someone else?
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Myself
Minor
I am making a referral for someone
Referral Source Information
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Referral Source Business Name
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Referral Coordinator/Provider Name
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Referral Source Phone number
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Referral Source Email or Fax
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Preferred Method of contact
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email
fax
phone
text
What type of organization are you referring from?
court or social services
hospital
inpatient facility
outpatient program
psychiatric care
physician's office
therapy practice
school
Patient First Name
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Patient Last Name
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Date of Birth
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-
Month
-
Day
Year
Date
If they/you will be using insurance, which insurance plan?
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Blue Cross
Blue Shield
Cal Optima
Medi-CAL
Medicare
Optum
Tricare
Aetna
Cigna
Magellan
Beacon (BMC (Wellsense)/Fallon/Unicare)
MassHealth/MBHP
Tufts/Harvard Pilgrim
UMR
Self Pay
What is the patient's medicaid or member ID number?
*
If self pay, please list "self pay"
Gender
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Male
Female
Non-Binary
Current pronouns
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He/Him
She/Her
They/Them
Primary Contact First and Last Name (if other than patient)
Primary Contact Cell phone
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Primary Contact Email
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Preferred Method of Contact: By selecting your preferred method of contact, you authorize us to communicate with you about testing and future appointments through this method. Message and data rates may apply. I can opt out at any time by emailing support@claritypsychologicaltesting.com or calling (781) 287-8676
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Phone
Text Message
Voicemail
Email
Address (street, city, state, zip code)
Patient's Living Situation
Lives with both parents
Lives with mother
Lives with father
shared custody/visitation schedule
lives alone
lives with partner/spouse/roommate
If you share custody, does the other parent know that you are pursuing testing for the child at the current time? Will they also want to be at the intake appointment or schedule a separate intake appt to go over their concerns? Please provide contact info of other parent if applicable
Parent or Guardian if applicable
What are your major concerns ?
Please let us know how you heard about us?
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friend/family
former patient
google search
psychology today
healthcare professional (please name in other and specialty)
group therapy practice
therapist
insurance provider
school
outside agency
Other
To improve the quality of our testing: we like to send your therapist our online therapist input form to be able to provide any valuable input they may have on your work together. Once received, this information is integrated into your report. If you have a therapist you have worked with in the past or are working with now whom you think would be helpful- please provide their email address or other contact info below. By providing this info below and signing, you are authorizing us to contact this outside party, acknowledging that you have engaged us for your neuropsychological testing, and ask for their input.
Signature
Please upload any relevant files to our HIPAA compliant server (prior testing, insurance info, payment info, relevant records, etc.)
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Please upload a copy of the front of the insurance card(s) you would like to use for your services Please make sure the image is not blurry.
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of
Please upload a copy the back of the insurance card(s) you would like to use for your services.
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of
Primary Subscriber (if not the patient)
Primary Subscriber DOB (if not the patient)
Primary Subscriber's Home Address
If you would like our office to share the results of you or your child's testing with anyone after testing is complete, please provide their contact info (website, email, phone, or fax) and role (teacher, therapist, counselor, pastor, doctor). By providing this info below and your signature, this will act as a release of information, granting us the ability to automatically share the results of testing after testing is complete. You can opt out at anytime by emailing Sarah@ClarityPsychologicalTesting.com
Signature
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