Referral Request Inquiry

Name: LifeTent Behavioral Health, LLC
Price range: $

Psychiatric Telehealth Services

Now accepting new patients in Massachusetts for medication management. Immediate appointments are available, with intake forms, consents, and questionnaires required within 48 hours before your consultation.

Submit your referral using the form below or fax the referral document and provide additional details by completing the short form. Remember to check the health insurance that we accept before you proceed. For questions, call or text us at (508) 635-0144 or click here to send a message.

Are you a clinician or individual who wants to refer a client for medication management? Complete and submit this referral form. Alternatively, fax the client’s referral documents to (508) 635-5414, include client’s legal name, date of birth, email address, cellphone number and insurance information. Remember to check the health insurance that we accept before you proceed. For questions, call or text us at (508) 635-0144 or click here to send a message.

Choose a button to send your referral.

Submit Referral Form

Patient's First Name

Patient's Last Name

Patient's Date of Birth

Patient's Gender

Patient's Address

Patient's Telephone / Mobile

Patient's Email Address (valid email is a must for telehealth service)

Reason for Referral

Patient's Payment Method

Insurance (In-Network) Self-pay (No insurance or out-of-network)

Patient's Pharmacy name and address?

(1a) Patient's primary health insurance company.

(1b) Patient's primary insurance policy number

(1c) Patient insurance plan group number

(2a) Patient's secondary health insurance company (if any)

(2b) Patient's secondary insurance policy number

How did you come across our company?

Any other information / comment you need to share?

Name of Referrer

Referrer's Organization or company

Referrer's business email

Referrer's business Phone number

Referrer's business Fax number

Upload referral document(s) if any

Consent

I consent to the collection and processing of the data provided in this online form, in accordance with the applicable privacy policy, for the purpose of providing mental health services. I understand that the information will be used solely for the intended purpose and will not be shared with third parties without my explicit consent. I also acknowledge that I have the right to withdraw this consent at any time by contacting LiteTent Behavioral Health, LLC.

Fax Referral Document

Patient's Legal Name:

Patient's Date of Birth:

Patient's Email:

Patient's Phone Number:

Patient's Insurance Companies:

Patient's Insurance Plan Number(s):

Reason for Referral:

Fax Referral Document to (508) 635-5414

I faxed the referral to (508) 635-5414

Referrer's Organization or Facility

What is Your Name?

What is Your Phone Number?

What is Your Email?

Comment:

New Patient Referral

Referral Request Inquiry

Psychiatric Telehealth Services

Submit Referral Form

Fax Referral Document

TeleHealth Visit

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New Patient Referral

Referral Request Inquiry

Psychiatric Telehealth Services

Submit Referral Form

Fax Referral Document

We accept new patients