Client Care – Request an Appointment/Make a Referral – Mental Health Counseling

Client Care - Request an Appointment/Make a Referral - Mental Health Counseling

Client Care Team Member

Early Inquiry Method*

Is this for you or someone else?

Myself

Someone else (parent/guardian on behalf of child)

I am making a referral for my client or patient

Not Sure

Client Information

First Name

Middle Initial

Last Name

Preferred Name or Nickname

Date of Birth

Current Age

Street Address

City

State

Zip Code

Email*

Phone

Gender Identity

Pronouns

Client's School (if child/adolescent)

Parent/Guardian Information

Parent/Guardian's First Name

Parent/Guardian's Last Name

Relationship to Client

Parent/Guardian Email

Parent/Guardian Phone Number

Referral Information

Referral Source's First Name

Referral Source's Last Name

Referral Source's Business Name

Referral Source's Relationship to the Client

Referral Source's Email Adress

Referral Source's Phone Number

Clinical Needs

[MHC] Presenting issue(s)

[MHC] Specific reason, i.e. particular event

[MHC] Goals of therapy

[MHC] Treatment history

[MHC] Taking medications

Yes

No

[MHC] Medications/prescribing doctor

Preferences

Therapist Name

Preferred Appointment Days

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred Appointment Times

Morning

Afternoon

Evening

Preferred Location(s)

Framingham

Newton

Westborough

Telehealth

Insurance Information

Using health insurance

Insurance Provider

First & Last Name on Insurance Card

Client gender as listed with insurance

Female

Male

Primary Insurance Member ID

Primary Insurance Group Number