Patient Referral Form Request

Name: LifeTent Behavioral Health, LLC
Price range: $

Psychiatric Telehealth Services

Yes, we accept new patients in Massachusetts. Our availabilities are Monday to Friday: 7 p.m. to 10 p.m., and Saturday: 9 a.m. to 10 p.m. We have an immediate appointment. Patient will be given 48 hours to fill out intake documentation before the initial consultation.

Are you a clinician 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. If you have questions about this form, call or text (508) 635-0144. or click here to send us a message.

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 (sorry we are don't accept MassHealth/Medicaid/Medicare)

(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.

New Patient Referral

Patient Referral Form Request

Psychiatric Telehealth Services

TeleHealth Visit

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We accept new patients