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603.865.1321
New London, Newport, Claremont, Plymouth and Upper Valley NH & Telehealth
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Adults
Children & Families
Teens
Couples
Substance Use
Wellness
Groups
Reduced Fee Clinic
School Services
Getting Started
Client Forms
About Us
Information for Clients
Our Therapists
Locations
Careers
For Professionals
Home
Locations
Contact
How We Can Help
Adults
Children & Families
Teens
Couples
Substance Use
Wellness
Groups
Reduced Fee Clinic
School Services
Getting Started
Client Forms
About Us
Information for Clients
Our Therapists
Careers
For Professionals
Professional Referral
Request an Appointment
Join Our Team
Professional Referral
(
*
required info)
Clients First Name
*
Clients Last Name
*
Date of Birth
* (mm-dd-yyyy)
Street Address
*
City, State & Zip
*
Parents Name
(if Client under 18)
Phone
*
(do not include 1- prefix)
Insurance Carrier
*
Secondary Insurance
ID Number
OK to Leave Message
*
Yes
No
Method of Contact
*
CA to call Patient
Patient will call CA
Location Preference
(availability limited)
New London
Upper Valley
Claremont
Newport
*
Plymouth
Alternate Location Choice
(* availability limited)
New London
Upper Valley
Claremont
Newport
*
Plymouth
Reason for Referral
*
Does client have any have any current or historical concerns with substance use?
*
Yes
No
If yes, please explain
Referral Source
*
Referral Contact
Referral E-Mail
*
Referral Phone
*
(do not include 1- prefix)
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