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Children & Families
Teens
Couples
Substance Use
Wellness
Groups
Medication Management
School Services
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Getting Started
Request an Appointment
Client Forms
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Information for Clients
Our Therapists
Locations
Contact
Careers
Client Portal Access
Professionals
Providers
Professional Referral
Join Our Team
Careers
Home
Locations
Contact
How We Can Help
Adults
Children & Families
Teens
Couples
Substance Use
Wellness
Medication Management
School Services
Groups
Getting Started
Getting Started
Request an Appointment
Client Forms
About Us
Information for Clients
Our Therapists
Locations
Contact
Careers
Client Portal Access
For Professionals
Providers
Professional Referral
Join Our Team
Professional Referral
Request an Appointment
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
If yes, please explain
Are these services mandated?
Yes
No
If yes, please note requirements
Referral Source
*
Referral Contact
Referral E-Mail
*
Referral Phone
*
(do not include 1- prefix)
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