BCPC Psychotherapy Clinic Inquiry Form

BCPC Clinic Referral Form

Complete the referral information below. Fields marked required must be filled out.
Client Information
Client Legal Name
Please note that we are required to ask this for insurance purposes
Client Chosen Name (if different from legal name)
Pronouns
(e.g. she/her, he/him, they/them, ze/zir, etc.)
Client Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip 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?
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
Insurance Information
Insurance Company (e.g. Healthfirst, United Healthcare, AmidaCare, etc.)
Type of Plan
Insurance Policy/Plan #
Person Insurance
Client Relationship to Insured
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