Part 1: General Info

Please accurately complete as many of the following questions as possible so that we can provide you with the help you need.  This form has administrative, physical and technical safeguards in place that are consistent with HIPAA requirements to protect privacy.  We check to see if new referrals have been submitted throughout the day, but please give us up to 24 hours to respond.  Please  do not hesitate to call us directly at 860-388-9656.

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* 1. What is your first name and what is your relation to the individual you are referring?

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* 2. What's the best way we can reach you?

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* 3. What is first and last the name of the person you are referring?

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* 4. What is the date of birth of the individual you are referring

Date

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* 5. What is the age of the person you are referring?

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* 6. What is the gender of the person you are referring?

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* 7. Tell us a little about the primary reason(s) you'd like to make a referral.  Check all that apply.

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* 8. Can you tell us if this person is currently taking any medications or if they have in the past, and if so, what the names of the medications are/were?  Please note whether medications are current or in the past.

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* 9. Can you tell us if the individual you are referring has been in treatment or therapy before, or if they've ever been hospitalized?

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* 10. Can you tell us if the individual you are referring has any past, current, or pending legal charges/issues?

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* 11. Can you tell us if the individual you are referring has any history or current self injurious behavior or suicidal ideation?

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* 12. Are there any health issues we should be aware of such as concussions, diabetes, thyroid issues, etc?

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