Thank you for contacting us. To begin the referral process, we need the following information. We will do our best to contact you shortly.
Today's Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Person Completing This Form
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First Name
Last Name
Relationship to Patient of Person Completing This Form
Patient Name
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First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client's Mother
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First Name
Last Name
Client's Father
*
First Name
Last Name
Legal Guardian
*
First Name
Last Name
At Therapy Zone, we believe children benefit most when families work together. We generally require consent from both parents or legal guardians before beginning treatment for anyone under 18. Special circumstances will be reviewed individually, always with the child’s best interests in mind and with family involvement as appropriate.
Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Insurance Company
*
Member ID # (If paying out of pocket, please indicate N/A)
*
Upload a picture of the front and back of your insurance card (if you choose not to upload this information now, it may delay the process of verifying your insurance and offering an appointment)
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Primary Cardholder's Name
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Primary Cardholder's DOB
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Why are you seeking therapy at this time?
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How were you referred to our office?
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Are you currently or have you ever experienced suicidal ideations or have been previously hospitalized for psychiatric reasons?
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Please indicate any medications you have been previously prescribed and/or currently taking.
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Is there any ACS involvement?
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Is there any history of substance use?
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Please indicate your availability for a recurring weekly appointment.When doing so, consider your travel time to the office and any standing weekly commitments. Providing times that are not realistically attainable may delay the scheduling process.Please note: Initial intake appointments may be scheduled at different times, if needed.
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Rows
Specific Times Available Starting in September
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday (limited)
Please indicate your availability--please be specific with days and times. Please take into account your travel time to the office and any weekly commitments. Giving
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Services/Therapist requested (if known)
*For Office Use Only*
Service Location Request
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Please Select
2281 Victory Blvd - Westerleigh
3710 Richmond Ave/4456 Amboy Road - Eltingville
Virtual/telehealth
No preference
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