Insurance Accepted!

Please complete this form to make a professional referral for a new client.

Date

YYYY

What agency/office are you referring from?

Referring Provider Name

First Name

Last Name

Referring Provider Email

Referring Provider Phone

(###)

###

####

Are you referring a Dependent whose Parent/Guardian is the main point of contact?

Parent/Guardian Name (if applicable)

First Name

Last Name

New Client Name

First Name

Last Name

Client/Guardian Phone

(###)

###

####

Client/Guardian Email

Client Date of Birth

YYYY

Are you requesting a particular therapist?

Presenting Issue

Preferred Location

Will the client be utilizing insurance benefits?

If so, who is the insurance carrier?

Primary Insurance Policy Number

Do you have a SECONDARY Insurance plan?

Yes

If yes, please include the Insurance Company Name, Policy number, Policy Holders Name and Birthdate here.

Are you utilizing EAP benefits?

This must be declared at the time of scheduling because we do not participate in all EAP programs.

Yes

EAP Authorization Number & Company

Schedule

Tell us a little bit about the client's availability so we can be sure we have a therapist that can provide consistency.

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