Real Help Referral Form

Outpatient Therapy:

Individual, Family, or Couples Counseling for adults and youth ages 5+ (with parent or guardian assistance) that address mental and behavioral health concerns provided virtually.

Medication Management:

Medication Management for clients 12 years and older.

MyselfMy child or dependentRefer a client

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

TherapyMedication ManagementBoth

MassachusettsNew HampshireNew YorkRhode Island

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.

WomanManTrans/Genderqueer/Non-binaryNo Preference

YesNo, I want to use my insurance

Please enter a valid phone number.

Referred by NFSWeb searchFriend or familyOther

Mental Health or Medical Providers: please attach clinical assessment(s), recent CANS, current treatment plan

Real Help Referral Form

SECTION 1 of 3: CLIENT INFORMATION

SECTION 2 of 3: CLIENT PREFERENCES

SECTION 3 of 3: INSURANCE INFORMATION