Referral Form

Health Insurance Plan or Self-Pay (I participate with plans listed below) *

Aetna

Anthem

Husky

Self-Pay ($150 for Intake, $135 for Individual or Family Sessions, $50 for Group Therapy)

Experience with Self-Injury or Disordered Eating: *

Date of Birth of Insurance Subscriber:

Client's Name: *

Name of Insurance Subscriber/Policy Holder:

Reason for Referral: *

Your Name: *

Client's Date of Birth *

Current School and Grade Level:

Phone *

Relevant Treatment Documents

Email *

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*As of February 2020, I am not accepting new clients as my practice is temporarily full. Please call Family Resource & Development Center, LLC at 860-351-3394 to be connected with an available therapist.

Referral Form

Past Trauma or Abuse: *

Address *

Current Special education Plan (504 or IEP):

Psychiatric History (Treatment Dates/Facilities):

Past/Current Diagnoses: *

Substance Abuse or Dependence (History of Use and Substances of Choice) *

Geoff Genser LCSW LLC

Individual Therapist

Specializing in Young Adult Treatment

Name of Psychiatrist/Medication Prescriber:

Insurance Subscriber Place of Employment:

Current/Past Psychiatric Medications: *

Today's Date: *

Siblings (Names & Ages):

Pediatrician

Parent(s)/Guardian(s) Names: *