Please note the following:

  • 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.

(If you would rather download a form that you can fill out and print, click here)

 
(* = Required)
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:
Policy Holder Name:
Policy Holder SS#:
 Policy Holder Employer:
Insurance Company: Aetna (Please note: Our psychologists are unable to take payment from Medicaid or other state insurance programs, and some psychologists are not covered by all insurance plans.)
  Anthem BC/BS
  Cigna
  Connecticare
  Healthnet
  Medicare 
  Other insurance:
    
  Alternative out-of-network 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
  Value Options
     (Patients with Value Options would need to use out of network benefits.)
  OptumHealth Solutions
  Mental Health Network
  United Behavioral Health
  Other Plan:
Insurance Policy #:
Insurance Phone #:
(for behavioral health benefits, usually located on back of the card)
Whom should we contact regarding this form?
Contact Person: Patient
  Other:
       Contact Name:
       Relationship to Patient:
Work Phone:
May we leave a message? Yes No
Home Phone:
May we leave a message? Yes No
Cell Phone:
May we leave a message? Yes No
* Email Address:
Please note the best  time to reach you:
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 Yes No
  In the past year Yes No
* Thoughts of harming or killing someone else? In the past 3 months Yes No
  In the past year Yes No
* Self-injurious behaviors?
(cutting, scratching, burning yourself)
In the past 3 months Yes No
  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 No
* Delusions?
(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?
(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:
Psychological or neuropsychological testing? Yes No
Any history of hospitalization for a psychiatric problem? Yes No
  If 'Yes', date of most recent hospitalization:

If 'Yes', why were you hospitalized?
Have you been to the Anxiety Disorders Center in the past? Yes No
Please report any formal psychiatric diagnoses that have been given:
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)
Note that the Accelerated CBT Program is not billable through insurance. Costs for the Accelerated CBT Programs are listed here.
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 3 PM
After 3 PM
(Check all that apply. If you require regular weekly appointments after 3PM, there may be an additional wait time to schedule your initial evaluation.)
security code
Enter code shown above:
  
 
 
 
 
 
 
Clinic Screening FormNote: If you would rather download a form that you can fill out and print, use the links below:

Clinic Referral Form (MS Word Format)
Clinic Referral Form (PDF Format)

Fax or mail your completed form to:

The Institute of Living
Anxiety Disorders Center
200 Retreat Avenue
Hartford, CT 06106

Fax: (860) 545-7156