Provider Therapy Referrals | Kimberlyfazzini Lcsw

Provider Psychotherapy Referrals

Please complete this form if you are another provider looking to make a referral for psychotherapy services.

Please note, in-home services are only available for individuals who are home-bound due to another diagnosis creating a hardship for them to get into the office. All other clients will be seen in-office or via telehealth if appropriate. Thank you!

Date and Time of Referral Submission:

Month

Day

Year

Time

HoursMinutes

Client First Name:

Client Last Name:

Address

Client Phone Number:

Client Email:

Client Date of Birth:

Month

Day

Year

Client Medicare Number (N/A if not applicable):

Primary Insurance:

Secondary Insurance:

Referring Provider - Name and best contact information:

Reason for referral? Potential diagnosis of concern?:

Client is looking for services in-office or in-home?:

In-office

In-home

Telehealth

The following questions are for in-home referrals only. Please put "N/A" if this does not apply to your client referral:

Does the client have telehealth capabilities?:

Does the client live alone? If not, who else resides in the home?

Are there any firearms in the home?

Are there any pets in the home?

Does the client or any other residents smoke in the home?

Does the client know they are being referred for services?:

Are there any other potential safety concerns at the client's home (hoarding, disconnected utilities, broken stairs, etc.)?:

Please upload any supporting documentation you feel is important we review or understand while establishing services:

Provider Psychotherapy Referrals

Kimberly Fazzini, MSW, LCSW, CCS

Kimberly Fazzini,
MSW, LCSW, CCS