Coastal Counseling Associates
24 Front Street, Exeter, New Hampshire 03833
(603) 778-0505, Fax
(603) 772-6761, www.coastalcouseling.com
Referral Form
The practitioners at Coastal
Counseling have provided this form to our community colleagues to better respond
to the needs of our mutual patients.
Please fill out the requested information and give this form to your
patient or either fax/mail with their permission to our office and we will
follow-up at our earliest opportunity.
It is our hope that when talking to your patients about the need for
psychotherapeutic or psychiatric assistance you will find a direct and responsive
group practice with Coastal Counseling Associates. This form will be
faxed/mailed back for your records and convenience
Referral source:
Referred by:
_________________________________________________________________________________________________
Patient
Information:
Patient Name: ____________________________________
Parent /guardian name: ______________________________________
Age: _______________ Date of
Birth: ________________
Insurance__________________________________________________
Address:
___________________________________________________________________________________________________
City:
___________________________________________________________________ State:
_____________ Zip: ____________
Phone #: (Home)
_____________________________________ (Work): ___________________________________
(ext) ________
Cell: _____________________________
Limitation due to confidentiality
______________________________________________
Presenting
Problem: Patient/parents chief concerns, problems, symptoms, or
issues that need assistance.
_________________________________________________________________________________________
_________________________________________________________________________________________
Services
requested:
[ ] Individual therapy [ ] Family
therapy [ ]
Psychiatric evaluation [ ]
Couples therapy [ ]
Co-Parenting [ ]
Behavioral Management
[ ] Group therapy [ ] School collaboration [ ] Other _________________________________________________
Insurance: Most insurance products accepted
Release of
information: Patient/parent/guardian consent to release of
information
.
The signature below indicates
the patient/parent/guardian has reviewed and approved the release of this
information to Coastal Counseling Associates.
Patient/Parent/Guardian
signature: __________________________________________________________________ Date: ________
Disposition: For Coastal Counseling Use only
Appointment Scheduled for
_____/_____/_____ No appointment scheduled for (Reason):
___________________________________
Referred outside the practice
(to) _________________________/ __________________________/___________________________
Please note if we are unable to meet the needs of your
patient we will provide 3 alternative referrals.