Third Party Referral - The Assessment Center At Solterra Academy

The Assessment Center At Solterra Academy

Submit a Third Party Referral

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- Early Signs of Autism
Insurance
Contact

Third Party Referral Form

Are you a doctor, pediatrician or mental health professional who has a student or young adult who needs an assessment? Please fill out our online referral form below and our team will be in touch with you to get an assessment scheduled.

Many insurances do not require a referral for an assessment so please check with your provider.

Referring Provider Information

Referring Provider

Date of Referral

Phone

Patients Information

Patient’s Name

Parent (if patient is a minor)

Date of Birth

Parent Telephone

Telephone (if over 18)

Parent email

Email (if over 18)

Insurance

ID #

Group Number

Policy Holder

We currently are contracted with: CIGNA, United Behavioral Health General and United Veterans Affairs Coordinated Care, Connecticare, Harvard Pilgrim, Choice Plus, UMR, Oxford Liberty, Oxford Freedom, Oxford Commercial, River Valley, Providence, and All Savers, and Anthem (includes Century Preferred PPO Network and Blue Cross and Blue Shield), and Husky.

Has this patient had a previous psychological evaluation: (if yes, when and with whom? If you have a copy of the previous report please scan and email to [email protected] or fax to: 860-612-2301, Attn: Assessment Center.

Yes No

If Yes, with whom?

Please indicate your reason(s) for seeking an assessment:

Developmental Delays Attention Executive Functioning Cognitive Issues Autism Routine oriented Social Issues Depressed Mood Anxiety, Fears, OCD Trauma Behavior/Emotional Regulation Psychosis Characterological Issues Risk/Safety Issue Other (explain):

Other reasons for an Assessment:

Please describe the clinical question(s) that you would specifically like testing to address:

Working diagnosis:

Documents Upload (**Please note there is a 256mg upload limit. For larger files please email [email protected])

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Home
Assessments
FAQS
Resources
- Early Signs of Autism
Insurance
Contact

Home
Assessments
FAQS
Resources
- Early Signs of Autism
Insurance
Contact

Third Party Referral Form

Referring Provider Information

Patients Information

Insurance

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Contact

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