Provider Referral Form

Provider Referral Form

Garden City Therapy, PLLC

www.GardenCityTherapy.com

This form is intended for healthcare providers and professional referrers only.
Provider or Entity Type*
Provider Name*
Entity Name*
Your Email*
example@example.com
Your Phone Number
Client Name*
Client DOB*

MonthDayYear
Date
Client Email*
example@example.com
Client Phone Number*
Insurance Carrier / Plan Name
Clients with Medicaid must have Managed Care plan such Fidelis Medicaid, Healthfirst Medicaid or UHC/Optum Community Plan Medicaid
Insurance ID*
Visit Reason or Symptoms:*

AnxietyTrauma or PTSDDepressionGriefStressDomestic ViolenceOCDDifficulty Adjusting to change in lifeRelational StrugglesCoping with illness/InjuryOther
Client outreach

Please reach out to client (checking this box confirms that client agreed to be reached out to/aware)After potential Intake, please ask client to complete ROI should client want further information shared.
Provider Outreach

I would like a clinician to reach out to me (referrer) to schedule a brief informational call (up to 15 minutes). Note: This call may not be with the future assigned therapist and is dependent on availability and client confirmation.Please notify me of outreach attempt (GCT can only confirm that an outreach attempt was made).Please let me know if you work with client insurance. Note: GCT can confirm whether we are generally in-network with a plan if sufficient information is provided. Eligibility and specific benefit details, however, are reviewed directly with client following contact with them).No response needed
Additional Notes: Below you may include therapist preferences, scheduling availability, or any general coordination details that may be helpful. Please do not include detailed clinical information or sensitive personal health information in this field.

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By submitting this form you understand that:*

Garden City Therapy is a private group practice providing routine outpatient mental health services and is not a crisis or emergency center. If a client is experiencing a crisis or requires immediate assistance, please contact 911, local emergency services, or the Long Island Crisis Center at (516) 679-1111.
This information is sent to our HIPAA-compliant email. Typical response time is within the same business day, and generally no longer than 48 business hours. Thank you.
www.GardenCityTherapy.com
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