Clone of Client Self-Referrals: Telehealth Individual or Group Therapy

Referral Form for Berkshire Heart and Mind Therapy: Group Therapy

To be electronically filled by clients completing self referral if over age 18 or by guardian if under age 18 (Founded by Colleen Passetto, LICSW cpassetto@colleenpassettolicsw.com)
Name of client you are referring:

First NameLast Name
Date of Referral

MonthDayYear
Which Group Therapy are you referring to?
Are you Referring yourself or someone else?
Referring Agency or Doctors Office Information
Name of Person or office referring client
Referring Person Or Practice Address
Referring Person or Practice Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring Prerson or Practice Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring Person's 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
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Client's Address
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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Please upload front and back images of your ID

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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:
Legal Guardian Name

First NameLast Name
Legal Guardian's Address
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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Referral Form for Berkshire Heart and Mind Therapy: Group Therapy

Referring Agency or Doctors Office Information

Clients Information

Reason for Referral

Legal Guardian Information:

Emergency Contacts Information

Medical Information