Client Referral Form for Professionals to Refer Clients:Telehealth Individual or Group Therapy

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:

First NameLast Name
Date of Referral

MonthDayYear
Is client being referred for individual therapy or group therapy (Choose all that apply)?
If the group is full, do you want to stay on a wait list for the next one?
Were you referred to us by Therapy Matcher?
If Yes and received our information from Therapy Matcher, Which clinician were you referred to at our Group Practice?
Clients Information
Name

First NameLast Name
Clients Preferred Name, Pronouns and gender if different then what is registered with insurance:
Date of Birth

MonthDayYear
Clients Gender (that insurance goes by):
Clients Age
Clients Primary Language
Patient Address

Address

Indirizzo Riga 2

CityNazione / Provincia

Post Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Clients PCP Name, Address and Phone Number:
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)
Primary Insurance ID Number
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
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.
Legal Guardian Information (complete only if client is under age 18):
Legal Guardian Name

First NameLast Name
Legal Guardian Address

Street Address

Street Address Line 2

CityState / 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 NameLast 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.
Should be Empty:

Client Self-Referral for Anxiety Telehealth Group s 18 and up

Clients Information

Reason for Referral

Legal Guardian Information (complete only if client is under age 18):

Emergency Contacts Information