Pride Outpatient Therapy/Med Management Referral Form

PRIDE Outpatient Therapy Referral Form

Including Medication Management
Our inclusive PRIDE Team consists of highly qualified mental health professionals and paraprofessionals who are a part of the LGBTQIA+ community. Our PRIDE Team is thoughtful in our choice of respectful language, behaviors, and continued education to best reflect the current needs and expectations of the LGBTQIA+ community."
Outpatient Therapy:

Individual, couples, and family therapy for ages 5+ for non-acute, mental and behavioral health. Services are provided in-pereson, via telehealth, or a combination of both. Treatment timelines are based on the client/family need.
Medication Management:

Medication Management for Adults 18 years and older. Our medication provider is female, English speaking only, and is based out of our Norwood, MA location.
Date of Referral:*

MonthDayYear
Date
Client's Legal Name:*

First NameLast Name
Client's Affirmed Name:*
Client's Date of Birth:*

MonthDayYear
Date
Client's Social Security Number:
Client's Gender Identity:*

Man or Boy (Cis)Woman or Girl (Cis)Transgender Man or Boy/Trans Man/MasculineTransgender Woman or Girl/Trans Woman/FeminineGenderqueer/Gender Expansive/Nonbinary/Neither exclusively male nor female
Client's Sex Listed on Insurance Plan:*

FemaleMale
Scheduling Preference (Day and Time of Day); Telehealth Services may be Available:*

MondayTuesdayWednesdayThursdayFridaySaturdayMorningsAfternoonsEarly Evenings
Language Needed for Service:*
Do you have an Outpatient Therapist gender preference?*

WomanManTrans/Genderqueer/Non-binaryNo Preference
Would you be willing to be assigned to an Outpatient Intern?*

YesNo
Do you have a preferred Therapist/Clinician you would like to see? Please provide their name:
Guardian Name:

First NameLast Name
Client/Guardian Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client/Guardian Phone Number:*
Please enter a valid phone number.
Client/Guardian Email:
example@example.com
Guardian's Preferred Language:
Need for Medication Management Services*

YesNo
If Yes, Please Explain:
Medication Management Only:*

YesNo
Insurance ID:*
Primary Insurance Type:*

MassHealth - Massachusetts Behavioral Health Partnership (MBHP)MassHealth - BeHealthy Partnership (MA MBHP Health New England)MassHealth - Beacon BMC Healthnet Plan Southcoast AllianceMassHealth - Beacon BMCHP QHP ConnectorCare Plan 1, 2 and 3MassHealth - Beacon Fallon 365 CareMassHealth - Beacon Wellforce Care PlanMassHealth - Tufts Health Direct ConnectorCare IMassHealth - Optum My Care Family (MA Allways Health Partners MCD)Commercial - Blue Cross Blue Shield of MACommercial - Blue Cross Blue Shield AnthemCommercial - Harvard Pilgrim (United Behavioral Health)Commercial - Optum United Health CareCommercial - Optum Allways Health PartnersCommercial - TuftsCommercial - Fallon Health Care
If able please upload a picture of the front and back of your insurance card

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Policy Holder:*

First NameLast Name
Policy Holder Date of Birth:*

MonthDayYear
Date
Policy Holder Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder Phone Number:*
Please enter a valid phone number.
Referred By:*

First NameLast Name
Referent Phone Number:*
Please enter a valid phone number.
Referent Agency: *
Referent Email: *
example@example.com
Presenting Problem/Issue:*
Why would this client/family benefit from working with the PRIDE team?*
Diagnosis:*
MH Providers: please attach clinical assessment(s), recent CANS, current treatment plan
File Upload

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PRIDE Outpatient Therapy Referral Form