Integrated Wellness Group

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

Adult Referral Form

If you are referring a child, please go back to the contact page and complete the 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
Name of Person submitting referral, if
different from above*
If there is no referrer, please
enter "Self" in these fields.
Referral Source Phone*
Referral Source Address*
Referral Source Email*
Medications*
Prescriber*
Reason for Referral*