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Who are you submitting this form for:

Referring Partner Information

Your First Name

Your Last Name

Your Phone:

###-###-####

Your Email

Name of the Organization you work for

Patient's Information

Patient's First Name

Patient's Last Name

Patient's Preferred Name:

Patient's Date of Birth:

##/##/####

Patient's Sex at Birth:

Patient's Preferred Pronoun:

Patient's Preferred Language

Patient's Mobile Phone:

###-###-####

Patient's Email:

Patient's Age

Patient's Address

Patient's Street & Apt #/PO Box:

Ex. 123 Main St

Patient's City:

Patient's State:

Patient's Zip Code:

Your Information

First Name

Last Name

Preferred Name:

Date of Birth:

##/##/####

Sex at Birth:

Preferred Pronoun:

Preferred Language

Mobile Phone:

###-###-####

Email:

Address

Street & Apt #/PO Box:

Ex. 123 Main St

City:

State:

Zip Code:

Your Information

What is your relationship to the client?

Your First Name

Your Last Name

Your Email

Your Phone

###-###-####

Your Preferred Language

Are you the biological parent?

Are you the legal guardian?

Is the child in foster care?

Is the client able to participate in verbal therapy?

Legal Guardian Information

Legal Guardian's First Name

Legal Guardian's Last Name

Legal Guardian's Phone

###-###-####

Foster Care Information

Foster Care Agency

Foster Care Contact First Name

Foster Care Contact Last Name

Foster Care Contact Phone Number

###-###-####

Foster Care Contact Email

Are you seeking services related to an Autism diagnosis?

Reason for Seeking Help:

Session Type Preference

NYPCC Location Interested In?

Hidden (NYPCC Location Selected)

How did you hear about NYPCC?

Are you receiving any mental health services elsewhere?

What types of service are being received from the provider?

Undetermined type of service receiving

Comments:

Insurance Information

Does the Patient have Medicaid?

Medicaid includes Medicaid Managed Care, Essential Plans, and Child Health Plus.

Do you have Medicaid?

Medicaid includes Medicaid Managed Care, Essential Plans, and Child Health Plus.

Medicaid Type

Insurance Company

Insurance Record ID

Medicaid ID

Member ID

Upload a copy of Medicaid Insurance Card

Does the Patient have any other forms of insurance?

Do you have any other forms of insurance?

Insurance Type

Insurance ID

Insurance Company/Plan

Upload a copy of the secondary form of your Insurance Card

Upload any documents you think will help NYPCC process this referral.

Consent "By checking this box, I confirm that the individual I am referring is aware of this submission and is interested in receiving mental health services."

Consent "By checking this box, I give consent to allow NYPCC to save the personal information I submit in this form. "

Consent "By checking this box, I give consent to allow NYPCC to send me text messages as needed for notifications and reminders "

Consent "By checking this box, I confirm that I am legally able to:
1 . Provide personal information about the prospective patient to NYPCC
2. Give consent on behalf of the prospective patient, to allow NYPCC to save the personal information I submit in this form. "

You indicated that you do not have Medicaid.

Please note that New York Psychotherapy and Counseling Center (NYPCC) is in-network with most Medicaid Managed Care plans, Child Health Plus, and Essential Plans. If your insurance falls under one of these categories, please go back and update your response to indicate that you have Medicaid. This will help us ensure your referral is processed correctly.