Outpatient Therapy Referral Form

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OUTPATIENT THERAPY REFERRAL FORM
Date of Referral: ___________ Office: _______________
Therapist Assigned: ____________________________
Referral Source: __________________________________
Phone: ______________________________________
Patient Name: ______________________________________________
DOB: ___________ Age: _____________
Address: _________________________________________________________________________________________
Phone Number: ________________________
Alternate Phone Number: ____________________
Ok to leave message:
Yes
No
Ok to leave message:
Yes
No
Person to be contacted for appointments: __________________ Service Requested:__________________________
Presenting Issue: __________________________________________________________________________________
Preference for male or female counselor or no preference: _______________________________________________
INSURANCE INFO
Insurance Carrier: _________________________
Policy Number: ______________________________________
(FPLIC, FPH, Highmark, and BCBS have a three letter prefix)
Subscriber Name: _________________________________
Subscriber DOB: ______________________________
Subscriber Address: _______________________________________________________________________________
Date and Time of Intake: ___________________________________________________________________________
Additional Comments: ______________________________________________________________________________
Referrals can be faxed for the Scranton Office at 570.955.5528 and for the Harrisburg Office at 717.695.0853

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