Referral Form

Phone *

Email *

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Date of Birth of Insurance Subscriber:

Address *

Client's Name: *

Relevant Treatment Documents

Past/Current Diagnoses: *

Today's Date: *

Substance Abuse or Dependence (History of Use and Substances of Choice) *

Insurance Subscriber Place of Employment:

Client's Date of Birth *

Licensed Clinical Social Worker and Individual Therapist

Specializing Adult Treatment

Experience with Self-Injury or Disordered Eating: *

Psychiatric History (Treatment Dates/Facilities):

Past Trauma or Abuse: *

Health Insurance Plan or Self-Pay (I participate with plans listed below) *

Aetna

Anthem

Husky

Self-Pay ($175 for Intake, $160 for Individual or Family Sessions, $50 for Group Therapy)

Name of Psychiatrist/Medication Prescriber:

Current Place of Employment or School:

Referral Form

Name of Insurance Subscriber/Policy Holder:

Your Name: *

Current/Past Psychiatric Medications: *

Primary Care Provider

Reason for Referral: *