Client Referral
Please complete this form if you are a healthcare clinician or facility looking to refer your client to Target Psychiatry for mental health treatment.
Date of Referral
*
-
Month
-
Day
Year
Date
Referring Clinician Full Name
*
First Name
Last Name
Referring Clinician Practice
*
Clinician Email
*
example@example.com
Reason for referral
*
Is the client aware of and agreeable to this referral?
*
Yes
No
Client Information
Client Name
*
First Name
Last Name
Client DOB
*
-
Month
-
Day
Year
Date
Name of Parent or Guardian (if under 18 years old). Please note Target Psychiatry currently treats clients 8 and older.
First Name
Last Name
Client Gender
*
Please Select
Male
Female
Non-Binary
Transgender Male
Transgender Female
Client Contact Number
*
Format: (000) 000-0000.
Client Email Address
*
example@example.com
Primary Insurance
*
Target Psychiatry is has in-network status with Aetna, Anthem, Carelon, Cigna, Blue Cross and Blue Shield plans, Harvard Pilgrim, Quest Behavioral Health, and Tufts (Point 32). Optum/United plans are pending credentialing (including MGB commercial). At this time, Target Psychiatry cannot accept primary MassHealth or Medicaid/Medicare plans.
Current psychiatric services received by client if any
*
please list any recent inpatient or partial hospitalizations
Is the client currently taking any psychiatric medication?
*
Yes
No
Unsure
Please list them.
*
Additional Comments?
please share safety concerns, if present
Please attach relevant documentation to help ensure continuity of care:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature
*
Submit
Should be Empty: