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

Preferred Office Location

Middlebury, CT

Shelton, CT

Telehealth

Reason for Referral

Reason for Referral

Primary Reason for Referral

Current Diagnoses

Current Medications

Treatment Team

Additional Clinical Notes

ROI

Release of Information

Upload a signed Release of Information (ROI) if available

Upload your ROI document here

Notice

Please note 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