BCPC Psychotherapy Clinic Inquiry Form

BCPC Clinic Referral Form

Complete the referral information below. Fields marked required must be filled out.
*Please note that at this time, we can only take on new clients who have a NYS-based Medicaid or Essentials plan. If you have a commercial/ employer-sponsored plan, you may continue to fill out this form if you'd like to receive tailored referrals for affirming providers elsewhere.*

If you have any questions, please contact lmottola@lgbtbrooklyn.org
Client Information
Client Legal Name
Please note that we are required to ask this for insurance purposes
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Chosen Name (if different from legal name)
Pronouns
(e.g. she/her, he/him, they/them, ze/zir, etc.)
Legal Sex
Please note that we are required to ask this for insurance purposes
Gender Identity
Primary Language
Preferred Language for Services
Note that we can only provide services in English at this time. If you are interested in services in another language, we can provide referrals.
Race
Ethnicity
Marital Status
Contact Information
Client Address

Street Address

Street Address Line 2
CityStateZip Code
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client's Cell Phone Carrier
(e.g. Verizon, T-Mobile, etc.)
If we call, can we leave a message on your phone?
Can we text your phone number?
Client Email Address
example@example.com
Ok to Email Appointment Reminders, etc?
What is the best way to contact you to follow up or coordinate appointments?
Offerings + Service Preferences
At this time, we are able to offer either:
1. Medium-term therapy for approximately 8 months with a social work student intern, OR
2. Long-term therapy (9 months or longer) with a licensed social worker.
**Note that if you'd like to work with someone for 8 months or less, we are only able to place you with an intern.**
Between the above options, what is your preference for length of time you'd like to work with someone?
Insurance Information

Please note that at this time, we can only take on new clients who have a NYS-based Medicaid or Essentials plan. If you have a commercial/ employer-sponsored plan, you may continue to fill out this form if you'd like to receive tailored referrals for affirming providers elsewhere.
Insurance Company (e.g. Healthfirst, United Healthcare, AmidaCare, etc.)
Listed here are the plans we accept. If you have a plan that is not listed and are looking for referrals elsewhere, please list your plan in the "other" field below
If other, please specify
Type of Plan
Please note that at this time, we can only take on new clients who have a NYS-based Medicaid or Essentials plan. If you have a commercial/ employer-sponsored plan, you may continue to fill out this form if you'd like to receive tailored referrals for affirming providers elsewhere.
Insurance Policy/Plan #
Person Insurance
Put your full name if this is your plan. If you are on someone else's plan, put the name of the person whose plan you are on (e.g. if you are under 26 and on a parent or guardian's insurance plan, or if you are on a spouse or domestic partner's plan)
Client Relationship to Insured
Select "self" if this is your plan. If you are on someone else's plan, select what your relationship is to that person.
Emergency Contact (Optional)
Emergency Contact Name
Emergency Contact Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship to Client
Ok to Call Emergency Contact's Phone?
Should be Empty:

BCPC Clinic Referral Form

*Please note that at this time, we can only take on new clients who have a NYS-based Medicaid or Essentials plan. If you have a commercial/ employer-sponsored plan, you may continue to fill out this form if you'd like to receive tailored referrals for affirming providers elsewhere.*

Client Information

Contact Information

Offerings + Service Preferences

Insurance Information

Emergency Contact (Optional)

Please note that at this time, we can only take on new clients who have a NYS-based Medicaid or Essentials plan. If you have a commercial/ employer-sponsored plan, you may continue to fill out this form if you'd like to receive tailored referrals for affirming providers elsewhere.