New Client Referral Form
Date
*
-
Month
-
Day
Year
Date
Client Name
*
First Name
Last Name
Legal Name (If Different)
First Name
Last Name
Date of Birth (MM/DD/YYYY)
*
Gender Identity
*
Pronouns
*
Sex Assigned at Birth (needed for Insurance/Billing purposes only):
*
Male
Female
Home/Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is it okay to leave a voicemail?
*
Yes
No
Email
*
example@example.com
Insurance Company Name
*
Please note that we do not accept Mainecare or Third Party Medicare Advantage Plans
Insurance Member ID# (including alpha prefix):
*
Emergency Contact Information
Please provide the name & contact information for whom we should contact in the case of an emergency:
Emergency Contact Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relation to Client:
*
If Client is a Minor
Please complete the following section if the client is a minor:
Guardian Name
First Name
Last Name
Relation to Client
Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian Email
example@example.com
Have you ever been a client at Art of Awareness?
*
Yes
No
If you responded "Yes" to the question above, please provide your past therapist's name:
Do you have a partner, friend, or family member who is working with an Art of Awareness therapist, and/or do you personally know or are related to an Art of Awareness staff member?
*
No
Yes
If you responded "Yes" to the question above, please provide the therapist's name:
Do you have a preference for sessions to be conducted in-person, by telehealth, or are you open to either?
*
In-person
Telehealth
I do not have a preference
Do you have a preference for weekly or biweekly sessions?
*
Weekly
Biweekly
I do not have a preference
Which type(s) of therapy are you seeking?
*
Individual Therapy
Couples Counseling (Open to all Partnership Constellations)
Family Therapy
Intern Services (For uninsured clients, or clients with Mainecare/Medicaid)
Which days and times are you available for sessions?
*
Please tell us more about which topics you would like to discuss in therapy:
*
Do you overuse or abuse any substances/alcohol/drugs?
*
Do you have disordered eating?
*
How did you hear about Art of Awareness?
Your website
Psychology Today
Facebook
Instagram
Email newsletter
Provider referral
Referred by a friend/family member
Other
If you were referred by another provider, please provide their Name & Practice Name
Submit
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