Client Self-Referral for Anxiety Telehealth Group s 18 and up
(To be completed by clients ages 18 and up)
Name of Person you are referring:
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First Name
Last Name
Date of Referral
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Month
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Day
Year
Date Picker Icon
Is client being referred for individual therapy or group therapy (Choose all that apply)?
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Coping with Anxiety Telehealth Support Group (ages 18 and up) Tuesdays at 10:00AM
Coping with Anxiety Telehealth Support Group (ages 18 and up) Wednesdays 4:00PM
If the group is full, do you want to stay on a wait list for the next one?
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Yes
No
Were you referred to us by Therapy Matcher?
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Yes
No
If Yes and received our information from Therapy Matcher, Which clinician were you referred to at our Group Practice?
Clients Information
Name
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First Name
Last Name
Clients Preferred Name, Pronouns and gender if different then what is registered with insurance:
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Date of Birth
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Month
-
Day
Year
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Clients Gender (that insurance goes by):
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Clients Age
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Clients Primary Language
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Patient Address
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Address
Indirizzo Riga 2
City
Nazione / Provincia
Post Code
Home Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Clients PCP Name, Address and Phone Number:
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Clients Insurance Company: Currently not accepting Medicare referrals (to be added at future date). If client has no insurance. select "No Insurance." No insurance and Out-Of-Network plans have hour fees listed on website. *Please Note: Clients will need to complete a 1 hour Intake to participate in group. If client does not have insurance or is Out-Of-Network, Out-Of-Pocket Cost is $200 for intake plus cost of each group session. (Choose Primary insurance and list also below if client has a second insurance)
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Aetna
Allies Choice HMO
Allies HMO
Anthem BCBS
BCBS Commercial Plans
Choice Easy Tier HMO
Choice Easy Tier PPO Plus
Cigna (Currently in Process of credentialling)
Complete HMO
Complete PPO Plus
Fallon Health (Atrius, Berkshire, Commercial, Fallon QHP, NaviCare Dual, Reliant and Wellforce)
Harvard Pilgrim
Health New England (Currently in Process of credentialling)
Mass General Brigham ACO
Masshealth FFS Medicaid
MBHP (including Stewart Health)
MGB Select and Plus
MGB Public Plans
OPTUM/UBH
Select HMO
TUFTS Commercial & Public Plans
UNICARE/GIC
Value HMO
WellSense Health Plans (BACO, BILH, Boston Children, Commercial, Commonwealth Care, EBNHC, HBE, Medicaid, MERCY, SIGNATURE, SOUTHCOAST)
WellSense Senior Care Options (SCO Medicaid)
* Client has No Insurance and is not aware of out-of-pocket cost
* I have no insurance and am aware of out-of-pocket cost for group is $50 per group session plus intake fee listed above due at day of session and intake.
* I have other insurance not listed above, do not have f Medicare and am aware of Out-Of-Network/Out-Of-Pocket cost for group is $50 per group session plus intake fee listed above due at day of session and intake.
Primary Insurance ID Number
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Primary Insurance Group ID
Secondary Insurance Type and ID Number
Secondary Insurance Group ID
Subscribers Name on Insurance (if other than client, please list name, address, relationship, phone number and DOB of Insurance subscriber):
Please upload front and back of your insurance cards. If you have secondary insurance, please also upload front and back of your insurance card.
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Reason for Referral
Reason for Referral
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Past and Current Mental Health Diagnosis History:
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Is Client being referred after a legal Guardian with Court Documentation? If yes, please complete Guardian Section Below.
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Yes
No
Legal Guardian Information (complete only if client is under age 18):
Legal Guardian Name
First Name
Last Name
Legal Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Guardian Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Legal Guardian Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Legal Guardian Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Legal Guardian Email
example@example.com
Emergency Contacts Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Client
Please tell us how you found out about our services.
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