Teen Anxiety and Coping Telehealth Support Group Referral form Thursdays at 3pm
To be electronically filled by adults ages 18 or older who are referring clients. Please note: Client (if over age 18) or Guardian (if client being referred is under age 18) will need to complete an intake session and may take 1-2 sessions to complete prior to the starting group. (Founded by Colleen Passetto, LICSW cpassetto@colleenpassettolicsw.com)
Name of client you are referring:
*
First Name
Last Name
If any preferences for therapist, please list below including if requesting specific clinician.
Date of Referral
*
-
Month
-
Day
Year
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Is client being referred for In-Person or Telehealth (Choose all that apply)?
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In-Person (Pittsfield, Massachusetts location)
Telehealth (Client must physically be in Massachusetts on days of Telehealth session)
Were you referred to us by Therapy Matcher?
*
Yes
No
If the current session for group is full, do you want to remain on the waitlist for the next available one?
*
Yes
No
If Yes and received our information from Therapy Matcher, Which clinician were you referred to at our Group Practice?
If No, where did you here about our Group Practice?
Person Placing Refferal's Information
Name of person and office referring client
*
Referring Person or office's Address
*
Address
Indirizzo Riga 2
City
Nazione / Provincia
Post Code
Referring Person or office's Phone Number
*
Please enter a valid phone number.
Referring Person or office's Fax Number
Please enter a valid phone number.
Email
*
example@example.com
Clients Information
Name
*
First Name
Last Name
Clients Preferred Name, Pronouns and gender if different then what is registered with insurance:
*
Date of Birth
*
-
Month
-
Day
Year
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Clients Gender (that insurance goes by):
*
Clients Age
*
Clients Primary Language
*
Patient Address
*
Address
Indirizzo Riga 2
City
Nazione / Provincia
Post Code
Home Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Clients PCP Name 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. (Choose Primary insurance and list also below if client has a second insurance)
*
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, Medicaid & Medicare, 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 and SCO Medicare)
Client has No Insurance and is not aware of out-of-pocket cost
Client has no insurance and is aware of out-of-pocket cost
Client has other insurance not listed above, not part of Medicare and is aware of Out-Of-Network/Out-Of-Pocket fees.
Insurance ID Number
*
Insurance Group ID
Subscribers Name on Insurance (if other than client, please list name, address, relationship, phone number and DOB of Insurance subscriber):
Secondary Insurance Type and ID Number
Secondary Insurance Group ID
If you or person you are referring has second insurance plan, please list which one and 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 copy of all insurance cards including secondary insurance card is person you are referring has more then 1 insurance.
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Reason for Referral
Reason for Referral
*
Past and Current Mental Health Diagnosis History (please list DSM and F code if known)
*
Is Client being referred under the age of 18? If yes, please complete Guardian Section Below.
*
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.
Legal Guardian Cell Phone Number
Please enter a valid phone number.
Legal Guardian Work Phone Number
Please enter a valid phone number.
Legal Guardian Email
example@example.com
Emergency Contacts Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship to Client
Medical Information
Relevant Medical History
*
Relevant Medical Records including ROI's for Care Coordination
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Please tell us how you found out about our services.
*
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