Referral Form Todays Date MM DD YYYY Name of referring Agent/Agency/ Parent/Guardian * Agency/ Facility Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email Agency/Facility Fax (###) ### #### Phone (###) ### #### Location of Service: Face - to - Face Zoom **Referred Client/Patient Information Name * First Name Last Name Date of Birth * MM DD YYYY Age * Gender * Grade Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Legal Guardian's Name * First Name Last Name Address of Guardian (if different) Address 1 Address 2 City State/Province Zip/Postal Code Country Email Cell Phone (###) ### #### Home Phone (###) ### #### Clinician Preference Female Male Language Preference Insurance Provider MBHP BEACON TUFTS BCBS Other Other Insurance MA Health Insurance ID # Services Requested * Outpatient Group Therapy Presenting Problem/Concern/Reason for Referral * Presenting Diagnosis / Symptoms: * DEPRESSION SCHIZOPHRENIA POST TRAUMATIC STRESS DISORDER ANXIETY AUTISM OBSESSIVE-COMPULSIVE DISORDER EATING DISORDER STRESS ADHD POOR COPING BIPOLAR DISORDER SUBSTANCE ABUSE ADJUSTMENT DISORDER Safety Concerns * Yes No Comments Medication(s) Psychiatrist/Prescriber Psychiatrist/Prescriber Phone (###) ### #### Current Provider ICC OP IHT Name/Agency PCP Medical Facility DYS/ DMH / DCF/ DDS Involved/Worker(s) Yes No School Based on the information provided/ referral screening does the service requested meet medical necessity? Yes No Your referral has been successfully submitted.
