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 (as seen on insurance):*

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

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

Transgender Woman or Girl/Trans Woman/FeminineTransgender Man or Boy/Trans Man/MasculineGenderqueer/Gender Expansive/Nonbinary/Neither exclusively male nor femaleWoman or Girl (Cis)Man or Boy (Cis)
Assigned Sex at Birth (as seen on insurance):*

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

Transgender Woman or Girl/Trans Woman/FeminineTransgender Man or Boy/Trans Man/MasculineGenderqueer/Gender Expansive/Nonbinary/Neither exclusively male nor femaleWoman or Girl (Cis)Man or Boy (Cis)No preference
Location Preference:*

In PersonTelehealthNo Preference
If Interested in In-Person Services Which Office Location Works Best for You?

Fall River, MADorchester, MALawrence, MAWest Springfield, MAWorcester, MA
Scheduling Preference (Day and Time of Day); Telehealth Services may be Available:*

MondayTuesdayWednesdayThursdayFridaySaturdayMorningsAfternoonsEarly Evenings
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:
Would you be interested in family focused therapy?*

YesNo
Guardian Name (if client is under 18):

First NameLast Name
Guardian's Affirmed Name (if different from above):

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
Mass Health/Primary Insurance ID:*
Secondary Insurance ID if applicable:
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 Plan / WellsenseMassHealth - 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 CareCommercial - Blue Cross Blue Shield Federal
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:*
Please identify how our Pride Team could support your needs:*
Diagnosis, if relevant:*
MH Providers: please attach clinical assessment(s), recent CANS, current treatment plan (if relevant)
File Upload

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Should be Empty:

PRIDE Outpatient Therapy Referral Form