Integrated Wellness Group

446A Blake Street, Suite 200
New Haven, CT 06515
203.387.9400

Child Referral Form

Please complete the following information. You can submit it online, or print it out, fill it in, and fax it to us at 888.772.2160
Questions? Give us a phone call at 203.387.9400

All fields marked with a * are required:


Services Requested:
Individual Therapy Group Therapy
Family Therapy
Client Name*
Client DOB*
Client Age*
Client Gender*
Client Primary Language*
Client Address*
City*
ZIP*
Client Phone Number*
Client Insurance*   enter "self pay" if none
Client Insurance Policy Number*   enter "not applicable" if none
Client SSN
Caregiver*
Caregiver Contact Information, if different from above
Is caregiver also the legal guardian?
Legal Guardian's Name*
Guardian Contact Information, if different from above
Guardian's Primary Language
 
Is DCF involved? * Yes No
Is DCF legal guardian? Yes No
DCF SW name
DCF SW phone
DCF SW office location
 
Name of Person submitting referral, if
different from above*
Name of Person submitting referral, if
different from above*
Referral Source Phone*
Referral Source Address*
Referral Source Email*
Medications*
Prescriber*
Reason for Referral*