Client First Name
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Client Last Name
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Client Preferred/Chosen Name
Client Date of Birth
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Client Email
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Client Phone
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Client Pronouns
He/Him
She/Her
They/Them
Provider Name
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Provider Organization/Company Name
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Provider Email
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Location Preference
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Westminster
Telehealth
Referral for What Service(s)?
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Therapy
Testing/Assessment
Both
Other (ADHD Coaching, etc.)
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Reason for Referral?
Abortion Support
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Experiencing Discrimination/Oppression
Gender Dysphoria
Gender Identity/Expression
Gender Transition
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Learning/Academic Concerns
LGBTQIA+
Obsessive-Compulsive Disorder (OCD)
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Self-Injury
Stress
Primary Insurance for Services
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Out of Pocket/Private Pay
Aetna : In-network
Cigna (Optum) : In-network
BCBS (Anthem) PPO : In-network
BCBS (Anthem) HMO : In-network
United Healthcare (UMR) : In-network
Colorado Medicaid: In-network with some plans
ComPsych (EAP)
ComPsych (Managed Care)
Medicare: Some Providers in-network
Tricare : Out of Network
Humana : Out of Network
Kaiser : Out of Network
Welltrack Connect (Texas)
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