Telehealth Counseling Referral Form

  • Telehealth Counseling Referral Form

    Including Medication Management

  • Outpatient Therapy: 

    Individual Counseling for adults and youth ages 5+ (with parent or guardian assistance) that provides long term, non-acute mental and behavioral health concerns provided via telehealth. Telehealth services for Outpatient Therapy is available.

  • Medication Management:

    Medication Management for clients 12 years and older. 

  • SECTION 1: CLIENT INFORMATION

  •  - -
  •  - -
  • Gender Identity:*
  • Would you be interested in the Pride Team for Outpatient Services. Our inclusive PRIDE Team consists of highly qualified mental health professionals and paraprofessionals who are a part of the LGBTQIA+ community. Our PRIDE Team is thoughtful in our choice of respectful language, behaviors, and continued education to best reflect the current needs and expectations of the LGBTQIA+ community."*
  • Need for Medication Management Services*
  • State where you Live*

  • SECTION 2: CLIENT PREFERENCES

  • Scheduling Preference (Day and Time of Day); Telehealth Services may be Available:*
  • Do you have an Outpatient Therapist gender preference?*
  • Would you be willing to be assigned to an Outpatient Intern?*

  • SECTION 3: CONTACT INFORMATION

  • Format: (000) 000-0000.

  • SECTION 4: INSURANCE INFORMATION

  • Primary Insurance Type Illinois:
  • Primary Insurance Type Massachusetts
  • Primary Insurance Type Rhode Island
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  •  - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • SECTION 5: REFERRAL INFORMATION

  • Format: (000) 000-0000.
  • How did you hear about us?*

  • MH Providers: please attach clinical assessment(s), recent CANS, current treatment plan

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