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Online Referral Form
Who is creating this referral?
Who is Submitting This Form?
I am a parent or submitting for myself
I am a hospital or school referring someone
Do you have health insurance?
--select an item--
Yes
No, I agree to pay for services out of pocket.
Insurance name
--select an item--
--Medicaid Plans--
EmblemHealth
MetroPlus
helthfirst
Amidacare
Medicare
Medicaid
Fidelis Care
Molina Health Care
United Healthcare
--Commercial Plans--
Oxford Health Plans
Oscar
United Healthcare
Cigna
aetna
Empire
1199SEIU united healthcare Workers Easl
AccessIPC
healthfirst
Optum
EmblemHealth
Magnacare
MetroPlus
HumanaCare
Is Patient Under 18?
--select an item--
Yes
No
First Name
Last Name
Patient Birthdate (MM/DD/YYYY)
Email Address
Patient Mailing State & Zip/Postal Code
United States
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua & Barbuda
Argentina
Armenia
Aruba
Ascension Island
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo - Brazzaville
Congo - Kinshasa
Cook Islands
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong SAR China
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR China
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
North Macedonia
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé & Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
St. Barthélemy
St. Helena
St. Kitts & Nevis
St. Lucia
St. Martin
St. Pierre & Miquelon
St. Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Address Line 1
Address Line 2
City
State
ZIP Code
Patient Phone Number
Please verify if our scheduling team can use text message communication to contact you
--select an item--
Yes, the Yes, the team can text me (Opt-in) team can text me (Opt-in)
No, I prefer phone calls and/or emails only (Opt-out)
Patient Primary Reason for Visit
--select an item--
ADD/ADHD
Addiction (Gambling, Video games, Pornography, Substances)
Adolescent/Teen Issues
Anxiety (Excessive worry)
Bereavement/Grief
Body Dysmorphia
Borderline Personality Disorder
Childhood Anxiety Issues
Chronic Illness
Depression
Family Conflict
Fertility Challenges
Impulse Control Disorders
LGBTQ Care
c
Mood Disorders
OCD/Phobia treatment
Panic Attacks
Parent Coaching
Play Therapy (therapy with children under 10 y/o)
Prenatal, Pregnancy, and Postpartum Concerns
PTSD Treatment
Relationship Issues
School issues (phobia, refusal, regulation)
Self Esteem Issues
Self-harm
Social Anxiety
Stress and Anger management
Trauma Counseling
Work Related Stress
How did you hear about us?
--select an item--
Insurance Company
Doctor or Therapist
Hospital
Family or Friend
Family or Friend
Social Media: LinkedIn or IG
ZOCDOC
Psychology Today
Google or Search Engine
Person Referring
Accept Condition
I have a dedicated Patient Care Coordinator
Submit