Referral Form

Patient Name *

First Name

Last Name

Patient Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Phone Number *

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Insurance Information *

Please select from our list of in-network insurance options. We provide claim forms upon request for out of network clients to submit to their insurance company after payment.

Anthem or Blue Cross Blue Shield

Community Health Options

Harvard Pilgrim (Point32Health)

United Behavioral Health

Martin's Point Generations Advantage

MaineHealth

US Family Health Plan

Out of Network

Type of Appointment-check all that apply *

Individual Therapy (age 18 or older)

Psychiatric Eval and Medication Management

Gender Affirming Care

Online DBT Skills Group (9 month commitment)

Referring Provider's Name *

First Name

Last Name

Referring Provider Phone *

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