Initial Outpatient Mental Health Treatment Request Form

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Instructions

Fields marked with an asterisk are required. The certification is not valid until a certification number is issued.

Clinician Information

Clinician's First Name

Clinician's Last Name

Please Specify "Other"

Clinician's NPI

Group's NPI

Outpatient clinics please use same NPI for both fields.

Phone Area Code () First Three Digits - Last Four Digits

Fax Area Code () First Three Digits - Last Four Digits

Clinician Email

Mailing Address 1

Address 2

ZIP Code

City

Contact's First Name

Contact's Last Name

Contact's Extension

Patient Information

Patient's First Name

Patient's Last Name

Date of Birth

mm/dd/yyyy

ID Card Number

Phone Area Code () First Three Digits - Last Four Digits

Patient Email

Clinical Information

What Service(s) Are You Requesting? (Check all that apply.)

Evaluation

Medication Management

Individual Therapy

Group Therapy

Family Therapy

Marriage Therapy

Diagnosis or Presenting Symptoms:

Diagnosis

Presenting Symptoms

Diagnosis

Presenting Symptoms Max characters: 200

Certification Start Date

Companion Benefit Alternatives, Inc.

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