Referral Form
Thank you for your interest in psychological services through Coastal CBT New England, LLC! We serve clients virtually in MA, CT, NH, and FL and have limited in-person availability in Lexington, MA. Completing this referral form is an important step in determining how we may be able to help you. If you prefer to speak via phone before completing this form, please do not hesitate to contact us at 857-201-2498. We are happy to first answer your questions, though will require this form before making a determination about moving forward with scheduling the initial evaluation. Once complete, Dr. O'Bryan will be in touch with you within 1-2 business days. Please note that Dr. Kraemer is not accepting patients at this time and does not maintain a waitlist. 

Parents: Please do not fill out this form for children age 18 or older. 

Your responses will not be reviewed immediately. This form should not be used in the event of, or to communicate, an emergency situation. If you are experiencing a mental health emergency and/or your physical safety is at risk, call 911 or go to the nearest emergency department immediately. You may also call the 988 Lifeline for 24/7 crisis support. 

Insurance: Dr. O'Bryan is in-network with Aetna and its subsidiaries, Carelon and Providence Health Plan, Anthem BCBS Connecticut, Anthem BCBS New Hampshire, and BCBS of Massachusetts. Patients with all other forms of private insurance are required to self-pay for services; however, Coastal CBT New England uses Thrizer for interested self-pay clients, permitting a co-pay at the time of treatment rather than the full out-of-network cost for those who have met their deductible. 

**By proceeding with the form below, you are indicating you do not have any form of Medicaid or MassHealth, or a a Medicaid or MassHealth ACO/MCO.**
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Patient's full legal name: *
Please tell us if you (patient) like to be called by another name.
What are your (patient's) pronouns? (optional)
Relationship to patient: *
Your name (if you are not the patient)
Do you (patient) have a conservator (someone legally responsible for making decisions for you)?  *
(For minor patients only): What is the current custody/guardianship arrangement? *
(For minor patient's only): If your response to the question above requested specification, please specify custody here. 
Patient's date of birth: *
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Patient's age: *
Patient's legal sex? *
Patient's address *
Patient's (or parent/legal guardian's) phone number: *
What is the best time to reach you (patient or parent/guardian)? *
Is it okay to leave a voicemail at this number? *
Patient's (or parent/legal guardian) email address: *
Is it okay to send you an email at this address? 
(While we cannot guarantee the security of electronic communications, we use a HIPAA-compliant encrypted email service called Paubox. Your email will also be used to set up a SimplePractice profile should we proceed. If you have not heard back from us within a week, be sure to check your spam/clutter folder.)
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Please list patient's primary form of health insurance: *
If patient's primary (not secondary) form of health insurance is Aetna (or a subsidiary), Anthem BCBS Connecticut, Anthem BCBS New Hampshire, Carelon, or Providence Health Plan, do you consent to patient's identifying information (name, date of birth, email) being added to provider's secure Alma portal prior to the first appointment in order to initiate an invitation to upload the patient's insurance details for billing purposes? Note that this step is necessary for using these forms of insurance coverage and, if declined, would necessitate self-pay. Patients with BCBS of MA should select N/A below. *
Please indicate whether you (patient) have any of the following primary or secondary forms of health insurance. *
Required
In a few sentences, please tell us what you (patient) are hoping to work on. *
To what extent have these problems interfered with your (patient's) functioning in the past month?
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Have you (patient) been previously evaluated or treated by Dr. O'Bryan or Dr. Kraemer? *
Do you (patient) currently have an individual therapist? *
If you have an individual therapist, what is the focus of your work (in a few words)?

 *
If you have an individual therapist, are you willing to consider pausing treatment with them should you initiate therapy through Coastal CBT New England? *
Have you (patient) engaged in any self-injurious behaviors such as cutting or burning in the past 12 months? Please do not consider skin-picking or hair-pulling in your response.  *
In the past year, have you (patient) done anything to prepare for or attempt suicide?

Please note: Your responses will not be reviewed immediately. If you are experiencing a mental health emergency and/or your physical safety is at risk, call 911 or go to the nearest emergency department immediately. You may also call the 988 Lifeline for 24/7 crisis support.
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Have you been hospitalized for psychiatric reasons in the past year? *
Please describe any alcohol or substance use (including prescribed cannabis) in the past 3 months, including type, amount, and frequency (e.g., alcohol- 2 glasses of wine, 3 nights per week) *
Has your (patient's) primary care physician indicated concerns that you are not meeting your nutritional or caloric needs (or, for minors, that they are not meeting expected weight gain/growth)? *
Do you (patient) have any ongoing difficulties with behaviors such as restricted eating or fasting, self-induced vomiting, misuse of laxatives or diuretics, or excessive exercise?  *
Please list any mental health diagnoses you (patient) have received from a healthcare provider. *
How did you hear about us? *
If applicable, please specify referral source.
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