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

Referral Form for Berkshire Heart and Mind Therapy: ADHD Consult and Clinical Evaluation

To be electronically filled by Agencies, Doctors offices and other professional placing referrals for clients to have ADHD Clinical Assessments. (Founded by Colleen Passetto, LICSW cpassetto@colleenpassettolicsw.com)
Name of client you are referring:

First NameLast Name
If any preferences for therapist, please list below including if requesting specific clinician.
Date of Referral

MonthDayYear
Is client being referred for individual therapy or group therapy (Choose all that apply)?
Is client being referred for In-Person or Telehealth (Choose all that apply)?
If for Group Therapy, please specify which group
If for ADHD Clinical Assessment, please specify which Clinician you are requesting:
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?
How did you hear of our ADHD Clinical Assessment Services?
Referring Agency or Doctors Office Information
Name of person and office referring client
Referring Practice Address

Address

Indirizzo Riga 2

CityNazione / Provincia

Post Code
Practice Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Practice Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
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 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)
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.
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
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.
Should be Empty:

Referral Form for Berkshire Heart and Mind Therapy: ADHD Consult and Clinical Evaluation

Referring Agency or Doctors Office Information

Clients Information

Reason for Referral

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

Emergency Contacts Information

Medical Information