Therapy Referral Form
Please complete the following form and our office will contact you to schedule a consultation!
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Who are you seeking therapy services for?
Please Select
Myself
Child/Minor
Spouse
Family
Other
If you select other, please specify on the line below:
Other:
Client Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Name (for child/minor)
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance
Please indicate who your insurance provider is from the list below of our accepted providers:
In-network providers:
Aetna
Blue Cross Blue Shield
Emblem Health/GHI (only NYCE PPO plan)
Cigna
Oscar
Optum
United Health Care
Member ID#
If you are not the primary insured, please provide the Name and Date of Birth of the policy holder:
Please upload or take a photo of the FRONT of your insurance card
*
Please upload or take a photo of the BACK of your insurance card
*
If we do not accept your insurance, are you interested in exploring:
Out-of-network benefits
Paying out of pocket
Reason for Services & Availability
Please give us a brief summary as to why you are seeking services with us:
What days and times are you available for therapy?
Should be Empty: