Anxiety Disorders Center
Center for Cognitive Behavioral Therapy
Clinic Referral Form
This form is to be completed by the patient, parent/legal guardian, or a person the patient has authorized to complete
this form. Please do not complete this form if you do not have the patient's consent. This form is not designed to
respond to psychiatric emergencies. If you are currently experiencing a psychiatric emergency, please contact your
current mental health provider or go to your nearest emergency room.
Information on individual in need of treatment:
Patient Name: _______________________
Date of Birth: _________________
Address:
Street 1_____________________
Street 2_____________________
City_______________________
State______ Zip__________
Country________________________
This referral is regarding:
Self
Child
Other: ___________
Insurance Information:
Name of policyholder: _______________________________
Policy Holder Social Security Number: __________________
Policy Holder Employer: ______________________________
Insurance company
(Please note that our psychologists are unable to take payment from Medicaid or other state insurance programs,
and some psychologists are not covered by all insurance plans listed below.)
Anthem BC/BS
Cigna
Healthnet
Aetna
Connecticare
Medicare
Insurance not listed or will not be using insurance
Alternative insurance with out of network benefits
Indicate insurance: _______________________________________
Will not be using insurance
Please provide information on treatment with a clinician in training
Who manages the behavioral health benefits?
Same as above
Mental Health Network
OptumHealth Solutions
United Behavioral Health
Value Options
(Please note that those with Value Options would need to use out of network benefits.)
Insurance Policy #: __________________________________________
Insurance Phone #: __________________________________________
(for behavioral health benefits, usually located on the back of the card)
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Anxiety Disorders Center
Center for Cognitive Behavioral Therapy
Clinic Referral Form
Whom should we contact regarding this form?
Patient
Other:
Work phone:
Contact Name: ____________________________
Relationship to Patient: ____________________________
_____________________
May we leave a message?
Yes
No
Home phone: _____________________
May we leave a message?
Yes
No
Cell phone:
_____________________ May we leave a message?
Email address: _______________________
Best Time to Contact You: _______________________
Yes
No
Current Symptoms/Treatment:
Please describe the problem you would like help with:
Are the following present:
Thoughts of harming or killing self?
In the past 3 months
In the past year
Thoughts of harming or killing someone else?
In the past 3 months
In the past year
Self-injurious behaviors?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
(cutting, scratching, or burning yourself)
In the past 3 months
In the past year
Yes
No
How often do you use drugs or alcohol (please list type, amount, and frequency)?
Have you ever been diagnosed with or had problems with the following:
Hallucinations (hearing things or seeing things that others don’t see or hear)?
Yes
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No
Anxiety Disorders Center
Center for Cognitive Behavioral Therapy
Clinic Referral Form
Delusions (e.g. belief that others are out to get you)?
Yes
No
Manic episodes (not needing sleep for days, racing thoughts, high risk behaviors)?
Yes
No
Has there been a history of developmental delays or a diagnosis of a developmental
disability (e.g. Autism Spectrum Disorder, Intellectual Disability, Non Verbal Learning
Disorder)?
Yes
No
Please describe any other psychiatric symptoms which may be causing a disturbance or
interfering with functioning at this time:
Current mental health treatment
None
Psychiatrist
Outpatient counseling
Partial Hospital
Psychiatric medication
Other: ______________________________________
Past Treatment History:
Have you been to the Anxiety Disorders Center in the past?
Yes
No
Any past Psychological or neuropsychological testing?
Yes
No
Any history of hospitalization for a psychiatric problem?
Yes
No
Date of most recent hospitalization: _____________________________
Why were you hospitalized?:___________________________________
Please report any formal psychiatric diagnoses that have been given:
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Anxiety Disorders Center
Center for Cognitive Behavioral Therapy
Clinic Referral Form
Other Information:
Who referred you to the Anxiety Disorders Center?
Are you interested in:
Group therapy
Individual therapy
Intensive therapy (OCD, Panic Disorder, School Refusal, Specific Phobia)
Research study
I am interested in information about other services outside the Anxiety
Disorders Center (e.g. medication management, support groups, self help
manual).
When are you available for regular weekly appointments?
Before 3PM
After 3PM
Fax or mail this completed form to:
The Institute of Living
Anxiety Disorders Center
200 Retreat Avenue
Hartford, CT 06106
Fax: (860) 545-7156
This form will be reviewed within 2 business days.
Rev. 11/17/14
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