Referral/Request for Services

New Patient Form

Step 1 of 4

Identification & Insurance
Important: When taking a photo of patient’s requested documents, please eliminate as much background as possible. Keep only the required document in the frame. Thank you.

Please upload a copy/image of your Drivers License, State Photo ID, or Passport. Please indicate if you/the patient has insurance. A copy of the front and back of the insurance card(s) is required to be uploaded. If you (the patient) do not have insurance, we encourage you to follow the link to apply for Medical Assistance once you have marked “No” to the insurance question below.
Please attach a copy/image of your Drivers License, State Photo ID, or Passport....*
Accepted file types: jpg, jpeg, png, gif.
If you are a Guardian/Parent of a Dependent/Child, please use your photo ID. IMPORTANT Please make sure that your photo is just of your card and reduce/remove as much of the background as possible.
Please attach a copy/image of your Drivers License, State Photo ID, or Passport....
Accepted file types: jpg, jpeg, png, gif.
If you have the ID of the Guardian/Parent of a Dependent/Child, please use the Guardian/Parent photo ID. IMPORTANT Please make sure that your photo is just of the card and reduce/remove as much of the background when uploading the picture as much as possible.
Do you have insurance?*
- Yes
- No
If you have not already done so, we encourage you to apply for Medical Assistance (MA) through the state of Pennsylvania.

CLICK HERE TO BE TAKEN TO THE MEDICAL ASSISTANCE APPLICATION
Primary Insurance Name*
Primary Insurance Member ID*
Primary Insurance Card*
Drop files here or

Max. file size: 2 GB, Max. files: 2.
Please attach a copy/image of the front AND back of your insurance card. IMPORTANT Please make sure that your photo is just of your card and reduce/remove as much of the background when taking your picture as much as possible.
Primary Insurance Card*
Drop files here or

Max. file size: 2 GB, Max. files: 2.
Please attach a copy/image of the front AND back of your insurance card. IMPORTANT Please make sure that your photo is just of your card and reduce/remove as much of the background when taking your picture as much as possible.
Primary Insurance Card
Drop files here or

Max. file size: 2 GB, Max. files: 2.
Please attach a copy/image of the front AND back of your insurance card. IMPORTANT Please make sure that your photo is just of your card and reduce/remove as much of the background when taking your picture as much as possible.
Primary Insurance Card
Drop files here or

Max. file size: 2 GB, Max. files: 2.
Please attach a copy/image of the front AND back of your insurance card. Since you have indicated you are an outside agency, if you do not have the card any print out for proof of coverage is appreciated. IMPORTANT Please make sure that your photo is just of your card and reduce/remove as much of the background when taking your picture as much as possible.
Do you have a secondary insurance?*
- Yes
- No
Secondary Insurance Name*
Secondary Insurance Member ID*
Secondary Insurance Card*
Drop files here or

Max. file size: 2 GB, Max. files: 2.
Please attach a copy/image of the front AND back of your insurance card. IMPORTANT Please make sure that your photo is just of your card and reduce/remove as much of the background when taking your picture as much as possible.
Secondary Insurance Card*
Drop files here or

Max. file size: 2 GB, Max. files: 2.
Please attach a copy/image of the front AND back of your insurance card. IMPORTANT Please make sure that your photo is just of your card and reduce/remove as much of the background when taking your picture as much as possible.
Secondary Insurance Card
Drop files here or

Max. file size: 2 GB, Max. files: 2.
Please attach a copy/image of the front AND back of your insurance card. IMPORTANT Please make sure that your photo is just of your card and reduce/remove as much of the background when taking your picture as much as possible.
Secondary Insurance Card
Drop files here or

Max. file size: 2 GB, Max. files: 2.
Please attach a copy/image of the front AND back of your insurance card. Since you have indicated you are an outside agency, if you do not have the card any print out for proof of coverage is appreciated. IMPORTANT Please make sure that your photo is just of your card and reduce/remove as much of the background when taking your picture as much as possible.

Service Offerings

Daytime and evening appointments are available Monday through Friday, and are often available within 48 hours.

Medication Name	Frequency	Amount	Prescribed By

Referral/Request for Services

New Patient Form

Step 1 of 4

Referral Source Information

Organization Information

Guardian/Parent Information

You have indicated that a Medical Power of Attorney exists. TEAMCare Behavioral Health will need a copy of this to share any information with the named POA.

You have indicated that a Custody Agreement exists. You will be required to supply this information to TEAMCare Behavioral Health prior to services starting.

Patient Demographic Information

Services, Concerns, and Interests

Background Information

988 Suicide Crisis Lifeline:

Dial and Call 988

Identification & Insurance

Service Offerings