Patient’s First Name: Kevin
Patient’s Last Name: Rodriguez
Patient’s Date of Birth: 2002-01-27
Patient’s Gender: Male
Patient’s Address: 10 Leon St W Village E Boston, MA 02115
Patient’s Telephone / Mobile: 845-625-4747
Patient’s Email Address (valid email is a must for telehealth service): retriever39@hotmail.com
Reason for Referral: Client is in last semester of college and reporting signs of anxiety and possible executive dysfunction including procrastination, “freeze state,” trouble focusing, forgetfulness, anxiety, difficulty prioritizing self-care (eating, sleeping, cleaning), distractability, low energy, low mood, low motivation
Patient’s Payment Method: Insurance (In-Network)
Patient’s Pharmacy name and address?: CVS
231 Massachusetts Ave
Boston, MA 02115
(1a) Patient’s primary health insurance company (sorry we are don’t accept MassHealth/Medicaid/Medicare): Blue Cross Blue Shield
(1b) Patient’s primary insurance policy number: NUQ962347527
(1c) Patient insurance plan group number:
(2a) Patient’s secondary health insurance company (if any): Select
(2b) Patient’s secondary insurance policy number:
How did you come across our company?: Word of mouth referral
Any other information / comment you need to share?: Client has seen by this writer for two outpatient therapy sessions.
Client’s mom and sister are both on medication (mom ADHD meds and sister anxiety meds)
Client’s listed address is local address. Mailing address (address that’s connected to insurance is a NY address).
Name of Referrer: Sheena Furnace, LMHC
Referrer’s Organization or company: Sanative Counseling and Wellness Center
Referrer’s business email: sfurnace@sanativecounseling.com
Referrer’s business Phone number: 508-780-0035
Referrer’s business Fax number:
Upload referral document(s) if any: https://lifetentcare.com/wp-content/uploads/elementor/forms/6722adf07f27b.pdf
Consent: on
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Date: 10/30/2024
Time: 6:06 PM
Page URL: https://lifetentcare.com/new-patient-referral/
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