Professional Referral – New Hampshire

(* required info) 
Clients First Name *
Clients Last Name *
Clients Email *
Date of Birth * (mm-dd-yyyy)
  Please select the client gender as it appears on their insurance card to ensure accurate claim processing.
We respect and welcome clients of all gender identities. This question is strictly for insurance billing requirements.
Gender * Male Female
Street Address*
City *
State *
Zip *
Parents Name (if Client under 18)
 (do not include 1- prefix)
Insurance Carrier *
Secondary Insurance
ID Number
OK to Leave Message * Yes No
Location Preference New London Upper Valley Claremont Plymouth Concord Keene Telehealth
Alternate Location Choice New London Upper Valley Claremont Plymouth Concord Keene Telehealth
Reason for Referral *
Attach a signed authorization from the client/patient regarding the release of their personal health information
(PDF only)
Does client have any have any current or historical concerns with substance use? * Yes No
If yes, please explain
Are these services mandated? Yes No
If yes, please note requirements
Referral Source *
Referral Contact
Referral E-Mail *
 (do not include 1- prefix)
 
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