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Referring Partner Appointment Request Form at Wellness Within

Welcome to Wellness Within Collaborative. If you are a referring partner or provider, please fill out this form. NOTE: Your client's email is REQUIRED so we can email intake forms to the client you are referring right away. Thank you!

Which agency/office are you referring from?*

If not listed, what is the name of the agency/office you work with?

Please Enter Your First Name:*

Please Enter Your Last Name*

Please Enter YOUR EMAIL Address*

Please Enter Your Phone Number*

What is Your Preferred Contact Method?*

Phone

Email

Both Phone and Email

What is the first name of the client you are referring?*

What is the last name of the client you are referring?*

What is YOUR CLIENT'S EMAIL (or the email of his/her guardian)?*

What is the client's phone number?*

Enter the Client's Gender Identity*

Client's Sexual Orientation

Client's Preferred Pronouns

Enter the Client's Date of Birth in this format: YYYY-MM-DD

What is the Parent/Guardian's First Name? (if applicable)

What is the Parent/Guardian's Last Name? (if applicable)

Select the primary reason that has led to this referral:*

Please briefly describe the reason for the referral:*

Please Select the Client's Insurance Provider*

Please Enter the Client's Insurance Member ID (Soc Sec # for VA Optum):

For Health New England - enter the last 2 digits of the Member ID:

Please enter the provider phone number from the back of the insurance card:

VA Optum, enter Authorization Number

VA Optum, Authorization Start Date

VA Optum Authorization End Date

Secondary Insurance Provider (if applicable)

Secondary Insurance Member ID

Street Address (This is used to verify insurance eligibility.)

City

State

Zip Code

Preferred Appt Time

Preferred Appointment Days

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Is there a specific therapist you'd like to request at our center?