External referral FORM

External Provider Referral Form

provider info

Provider Information

Date of Referral

Referring Provider Name

Provider Title / Credentials

Practice / Organization Name

Phone Number

Email Address

Fax Number

client info

Client Information

Client Name

Date of Birth

Gender Identity

Pronouns

Address

City

State

Zip Code

Phone Number

Parent / Guardian Name

Parent / Guardian Phone Number

Primary Insurance

Insurance ID / Member Number

Secondary Insurance

Insurance ID / Member Number

Reason for Referral

Reason for Referral

Primary Reason for Referral

Client's location preference

Client's location preference

Preferred Office Location

Middlebury

Shelton

Telehealth (virtual)

Current Diagnoses label

Current Diagnoses

List all relevant medical diagnoses

Current meds label

Current Medications

List all current psychiatric and relevant medications along with their dosages

Treatment Team Label

Treatment Team

List all medical providers relevant to this client's care

Additional Clinical Notes

Additional Clinical Notes

Please provide any additional information that you feel may be relevant to this client and their referral

ROI

Release of Information

Upload a signed Release of Information (ROI)

Upload your ROI document here

Notice

Please know that BHC does not provide crisis intervention services. In the event of a psychiatric emergency, please direct the client or family to the following resources:

Emergency Services: 911
Connecticut Crisis Line: 211
National Suicide & Crisis Lifeline: 988