Professional Referral

(* required info)

Clients First Name *

Clients Last Name *

Clients Email Adr *

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

New London Upper Valley Claremont Plymouth Telehealth

Alternate Location Choice

New London Upper Valley Claremont Plymouth Telehealth

Reason for Referral *

Attach a signed authorization from the client/patient regarding the release of their personal health information
(PDF only)

Does client have any have any current or historical concerns with substance use? *	Yes No Please choose yes or no
If yes, please explain
Are these services mandated?	Yes No Please choose yes or no
If yes, please note requirements

Referral Source *

Referral Contact

Referral E-Mail *

Referral Phone *

(do not include 1- prefix)