NH Outpatient Med Management Referral Form

NH Outpatient Therapy Referral Form

Including Medication Management
Outpatient Therapy:

Individual Counseling for adults and youth ages 5+ (with parent or guardian assistance) that provides long term, non-acute mental and behavioral health concerns provided via telehealth. Telehealth services for Outpatient Therapy is available.
Medication Management:

Medication Management for clients 12 years and older.
Today's Date:*

MonthDayYear
Date
Client's Legal Name:*

First NameLast Name
Client's Affirmed Name:*
Client's Date of Birth:*

MonthDayYear
Date
Client's Gender Identity:*

Man or Boy (Cis)Woman or Girl (Cis)Transgender Man or Boy/Trans Man/MasculineTransgender Woman or Girl/Trans Woman/FeminineGenderqueer/Gender Expansive/Nonbinary/Neither exclusively male nor female
How did you hear about us?
Location Preference:*

In PersonTelehealth
If Interested in In-Person Services Which Office Locations Work Best For You?

ManchesterLaconiaLancaster
Scheduling Preference (Day and Time of Day); Telehealth Services may be Available:*

MondayTuesdayWednesdayThursdayFridaySaturdayMorningsAfternoonsEarly EveningsEvenings (By Appointment Only)
Language Needed for Service:*
Do you have an Outpatient Therapist gender preference?*

WomanManTrans/Genderqueer/Non-binaryNo Preference
Would you be willing to be assigned to an Outpatient Intern?*

YesNo
Do you have a preferred Therapist/Clinician you would like to see? Please provide their name:
Guardian Name:

First NameLast Name
Client/Guardian Address:*

Street Address

Street Address Line 2

City

Zip Code
Client/Guardian Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Client/Guardian Email:*
example@example.com
Guardian's Preferred Language:
Need for Medication Management Services*

YesNo
If Yes, Please Explain:
Insurance ID:*
Primary Insurance Type:*

CommercialMedicaid
If able please upload a picture of the front and back of your insurance card

Cancelof
Insurance Policy Holder Name:*

First NameLast Name
Insurance Policy Holder Date of Birth:*

MonthDayYear
Date
Insurance Policy Holder Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Policy Holder Cell Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Policy Holder Home Number:
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Policy Holder Work Number:
Please enter a valid phone number.Format: (000) 000-0000.
Referred By:

First NameLast Name
Referent Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Referent Agency:
Referent Email:
example@example.com
Presenting Problem/Issue:*
Diagnosis:*
How did you hear about Northeast Family Services?*

NFS WebsiteFriend or FamilyReferred by another agencyYouTubeInstagramFacebookTikTokWebinar seriesOther
MH Providers: please attach clinical assessment(s), recent CANS, current treatment plan
Should be Empty:

NH Outpatient Therapy Referral Form