Mountaineer Psychological Services

Referrals

New! Provider/Advocate Quick Referral Below

Referral Forms

Submit your information here —no need for a medical referral

Please carefully select form. If you are seeking evaluation and therapy services, please complete both forms

therapy referral form

evaluation referral form

therapy referral form (PDF)

therapy referral form (online)

evaluation referral form (PDF)

evaluation referral form (online)

Therapy Referral Form

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- Step 1 of 6

I am seeking

Please complete this form only if you are seeking mental health treatment in the form of individual, couples, or family therapy/counseling. If you would like to request a comprehensive evaluation with psychological assessment, please complete the Evaluation Referral form instead. If you would like an evaluation and therapy services, please complete both forms. Please note we do not have any prescribing providers, so we cannot offer any medications.

Patient Name *

First

Last

Name the patient goes by

Please indicate if the person prefers to be addressed by a nickname, uses middle name, goes by a different name, etc.

Type of Therapy Requested *

Individual
Couples
Family

Please identify what type of treatment you are interested in. If services are for a child, these are typically individual.

This referral is for *

an Adult
a Child

Who is authorized to provide consent for this patient? *

Self
Biological Parent
Other

Adults must complete their own referrals (i.e., an appointment cannot be made by a parent, spouse, friend, etc. for another adult unless they have guardianship). Children in foster or kinship placement need to have consent from the person/agency with medical decision-making authority.

Please explain: *

Indicate if there is a guardianship situation, if the person is living with someone but another (or the state) has custody, etc.

Treatment is: *

Voluntary
Recommended
Ordered

Adults and children should be made aware of and agree to participate in therapy/counseling services. Therapy/counseling should not be used as a threat or consequence.

Recommended or Ordered by:

Please indicate who recommended or ordered treatment

Date of Birth *

MM/DD/YYYY

Age *

Sex *

Male
Female

Gender Identity

Male (Cisgender--born male and identify as male)
Female (Cisgender--born female and identify as female)
Nonbinary
Transgender
Other

SSN *

Needed for some insurance verification. Will not be shared. Enter zeros if not available or you prefer not to share online.

Any involvement with the legal system (Courts, DHHR, CPS, Probation, Divorce, etc.) *

Yes
No
In the past

Nature of legal involvement *

Treatment is Court Ordered
CPS/Abuse and Neglect
Foster Care
Criminal Charges or Delinquency
Probation
Truancy
Pending Charges
Civil (Worker's Comp, Personal Injury, etc.)
Divorce
Substance Use Issues
Other

Has a CAC evaluation/forensic interview been completed? *

Yes
No
Pending

Person completing this form (Referral Source) *

Self
Parent/Guardian
Therapist
Medical Provider
Case Worker/Attorney/Probation Officer
School Personnel
Other

If a provider recommended you seek treatment, you will be able to indicate that in a different field. The Referral Source on this form should be the person completing the form.

Referral Source Name *

First

Last

Please provide contact name (not agency or clinic)

Parent or Guardian Name *

First

Last

Referral Source Email *

Please provide your email for coordination of care and updates. This will not be shared with client.

Referral Source Phone Number *

Relation to Patient: *

Agency/Organization *

Agency/Organization Phone Number

Agency/Organization Fax Number

Patient Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient/Guardian Telephone Number *

Is this a...

mobile
home
work line

Patient/Guardian Email *

Needed for scheduling

Payment Choice *

Private Pay
Commercial Insurance
Medicaid
Medicare

Insurance information is needed to verify coverage prior to scheduling. Please provide information for all forms of coverage below. Please do not select private pay unless you do not have or do not intend to use insurance coverage.

Is there more than one form of coverage? *

Answer should be Yes if there are primary and secondary commercial insurance plans, commercial as primary and Medicaid secondary, Medicare and Medicaid, or any other combination of coverages. HSAs do not need to be listed.

Primary Insurance Carrier *

Insurance Company Contact Number

Policy Number *

Group Number

Policy Holder's Name *

First

Last

Policy Holder's Date of Birth *

MM/DD/YYYY

Policy Holder's Social Security Number

Policy Holder's Relation to Patient *

Medicaid or Medicare ID Number *

This is the number on your card--it should not be your SSN

Medicaid or Medicare Plan Name *

For Medicaid, this should be the name of your MCO (e.g., Aetna Better Health, The Healthplan...). For Medicare this should be the title of your plan (e.g., Humana Advantage Silver)

Secondary Insurance? *

Secondary Insurance Type *

Commercial
Medicaid
Medicare

Medicaid or Medicare ID Number (secondary) *

This is the number on your card--it should not be your SSN

Medicaid or Medicare Plan Name (secondary) *

For Medicaid, this should be the name of your MCO (e.g., Aetna Better Health, The Healthplan...). For Medicare this should be the title of your plan (e.g., Humana Advantage Silver)

Name of Secondary Insurance Plan *

List commercial insurance name (e.g., Highmark, Peak,)

Policy Number (secondary) *

Group Number (secondary)

Policy Holder's Name (secondary) *

First

Last

Policy Holder's Date of Birth (secondary) *

MM/DD/YYYY

Policy Holder's Social Security Number (secondary)

Policy Holder's Relation to Patient (secondary) *

Please briefly describe presenting concern(s): *

Please indicate symptoms, behaviors and how they are causing impairment. This information is important to match patients with the most appropriate provider.

Attach any files related to seeking treatment

Click or drag files to this area to upload. You can upload up to 3 files.

This might be a copy of a court order, a referral from a medical or mental health provider, a recommendation from a probation officer or caseworker, or other documents related to seeking or being recommended for treatment

Has the patient requested or been recommended to seek any particular type of intervention?

Please describe if a specific therapeutic approach is requested. Examples of this may include specific interventions like CBT, DBT, EMDR, PCIT, ERP, HRT, CBIT, ACT, CPT, EFT, IFS, etc. More general treatment requests can also be outlined (e.g., social skills training, coping skills, anger management, attachment work, parent management training, cognitive restructuring, etc.).

Has the patient EVER talked with a psychiatrist, psychologist, or other mental health professional? *

Yes--therapy/counseling only
Yes--medication only
Yes--therapy/counseling and medication
Yes--evaluation only
No

Please list approximate dates & diagnoses/reasons for treatment: *

Is the patient currently receiving mental health treatment? *

Yes--therapy/counseling
Yes---medication
Yes--therapy/counseling and medication
No

Please describe: *

Please provide the names of current providers and where they practice (e.g., therapy with Jane Doe of Wellness Life Counseling, medication from Dr. Smith of WVU Medicine) and current medication(s).

Has patient been HOSPITALIZED for mental health reasons? *

Please list approximate dates & reasons: *

Has the patient ever had a psychological EVALUATION? *

Please list approximate date(s) & reason(s) and indicate if any diagnosis was rendered: *

Please attach any previous reports or records here

Click or drag files to this area to upload. You can upload up to 3 files.

Has the patient ever been evaluated for academic/developmental concerns? *

Yes, and details or a report are available
Yes, but no details are available
No

Describe with approximate dates and findings *

Attach available records

Click or drag files to this area to upload. You can upload up to 3 files.

If there is a current IEP, 504, etc. or previous report is available, please attach here.

Does the patient have any significant MEDICAL issues? *

Please describe: *

How did you hear about us? *

Preferred Therapy Method *

In Person
Telehealth
Either

Telehealth appointments require reliable internet connection with audio and video

Is the patient able to commit to weekly or bi-weekly sessions at this time? *

Yes
Maybe
No

It is important and best practice for patients to be seen regularly. If the patient cannot commit to regular sessions, please consider scheduling when treatment can be appropriately prioritized.

Provider Preference: *

Male Provider Only
Female Provider Only
Male Provider Preferred
Female Provider Preferred
No preference

Clinician Requested:

First Available
Jennifer Myers, PhD
Stacey Crandall, LPC
Amy Zeiders, LICSW
Ellis Moran MA
Thomas Ewell MS
Ric Renquest MA, LPC
Jennifer Adams, MA, LPC
Rachel Dunn, LGSW
No Preference

Evaluation Referral Form

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- Step 1 of 8

I am seeking *

Please complete this form only if you are seeking a comprehensive evaluation with psychological assessment. If you are seeking treatment, please complete the Therapy Referral form instead. If you are looking for both services, please complete both forms.

Patient Name *

First

Last

Name the patient goes by

Please indicate if the person prefers to be addressed by a nickname, uses middle name, goes by a different name, etc.

This referral is for *

an Adult
a Child (5-11)
an Adolescent (12-17)

We do not currently offer evaluations for children under the age of 5.

Who is authorized to provide consent for this patient? *

Self
Biological Parent
Other

This evaluation is: *

Wanted
Recommended
Ordered/Required

Recommended or Ordered by:

Who recommended or ordered this evaluation?

Patient Date of Birth *

MM/DD/YYYY

Age *

Sex *

Male
Female

Gender Identity

Patient Social Security Number *

Needed for some insurance verification. Enter zeros if you prefer not to provide online.

Person completing this form (Referral Source) *

If a provider recommended you be evaluated, you will be able to indicate that in a different field. The Referral Source on this form should be the person completing the form.

Referral Source Name *

First

Last

If a provider recommended you be evaluated, you will be able to indicate that in a different field. The Referral Source on this form should be the person completing the form.

Referral Source Email *

Please provide your email for coordination of care and updates

Parent/Guardian Name *

First

Last

Referral Source Phone Number *

Relation to Patient *

Agency/Organization

Please describe the agency, practice, firm, etc. you are affiliated with

Agency Phone Number

Agency Fax Number

Patient (or Guardian) Email Address *

Please provide an email for the person to be contacted for consent and scheduling. Email is our primary method of client communication.

Patient Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient/Guardian Telephone Number *

Is this a...

mobile
home
work line

Is this evaluation court-ordered? *

If so, please attach a copy of the court order

Click or drag a file to this area to upload.

Court order is needed before any appointment can be scheduled

Is there any past or current involvement with the legal system or social services (e.g., CPS, DHHR, Probation) *

If so, please describe *

Please include specific information regarding the situation. Names of caseworkers, attorneys, probation officers, etc. should be provided if possible. For children, please indicate who can provide consent for the evaluation.

Please attach any relevant records

Click or drag a file to this area to upload.

This could include court documents, MDT reports, Family Functioning Assessment, etc.

Any current/ pending LEGAL charges? *

Please describe:

Next Court Date (or timeframe for when report is needed):

Note: We cannot guarantee meeting any time constraints. This is for informational purposes only.

What is the purpose of the evaluation? *

Diagnostic Clarification & Treatment Recommendations
Forensic (involvement with the legal system)
Second Opinion
Other

*Forensic evaluations (competency/criminal responsibility, risk assessment, parental fitness...) should be court ordered and/or referred by an attorney/caseworker/probation officer, etc. These are not typically covered by insurance. We do NOT accept Medicaid/Medicare for any forensic evaluation. If a second opinion is requested for a forensic/legal evaluation, a court order will likely be required (i.e., we do not accept self-referrals for these). *If a second opinion is requested for a clinical or forensic report, a copy of the previous report and/or records from previous treatment will be required.

Question(s) to be answered with the evaluation *

What are you trying to determine with this evaluation? This should be a question (e.g., Do I have ADHD? Does my child need accommodations at school? Is the person competent to stand trial?) We do NOT offer custody evaluations.

Nature of the patient's presenting concern(s): *

suspected ADHD
suspected ASD
Trauma
Clinical mental health concerns (anxiety, depression, grief, etc.)
Behavioral concerns (aggression, acting out, defiance, self-harm, etc.)
Substance Abuse
School/Academic concerns
Developmental concerns
Legal: Competency, Parental Fitness, Truancy, Risk Assessment, etc.
Gender Affirming Care (Need letter for treatment)
Pre-employment Screening
Pre-surgical Screening
Other: please add below

Other: *

Has a Forensic Interview (usually via Child Advocacy Center) been conducted? *

Yes
No
Pending

If child abuse or neglect is suspected, the first step is usually a forensic interview.

Briefly describe the details of the presenting concerns: *

Include symptoms, behaviors of concern, and areas where these are causing impairment

PREVIOUS mental health treatment? *

Yes--therapy/counseling
Yes--medication
Yes--therapy/counseling and medication
No

Please describe past diagnoses, treatment types/interventions, and effectiveness, etc. *

Include name(s) of provider(s), medication(s) if available.

Please attach any available records

Click or drag files to this area to upload. You can upload up to 3 files.

Previous Psychological Evaluation(s)? *

Yes, and a report or results are available
Yes, but no information is available
No

If there were any previous evaluations, those records are important and would be helpful to the evaluator.

Please Describe: *

Include name(s) of provider(s), medication(s) if available.

Please attach available report(s)

Click or drag files to this area to upload. You can upload up to 3 files.

Include any records related to past psychological evaluations.

Previous testing by or for school for learning or behavioral issues? *

Yes
Recommended but did not
No

Please indicate if there was any testing for IQ, Achievement, Giftedness, Learning Disorders, ADHD, Developmental or Behavioral issues.

Please Describe

Indicate any testing or assessment, approximate date(s), and findings if available.

Any past or current school based interventions?

Yes, current
Yes, in the past
No

Please describe any school-related diagnoses, treatment types/interventions/accommodations, and effectiveness. *

Include summary of IEP, SAT, 504 plan, alternative educational arrangements, medication management, etc.

Please attach any reords related to academic/behavioral interventions

Click or drag files to this area to upload. You can upload up to 3 files.

This could be IEP, 504, SAT, etc. If there is a current plan in place, that will need to be reviewed prior to the evaluation interview.

Prior HOSPITALIZATION for mental health reasons? *

Please list approximate dates & reasons:

CURRENT mental health treatment or medication? *

Yes--Therapy
Yes--Medication
Yes--Therapy and Medication
No

Note: Some assessment services may not be approved by Medicaid if there is no previous or current mental health or psychiatric treatment.

Please describe: *

Include name(s) of provider(s), medication(s) if available.

Please attach any additional records here:

Click or drag files to this area to upload. You can upload up to 3 files.

Are there any limitations (literacy issues, communication problems, physical issues, etc.) which might need to be considered for the evaluation? *

Please describe: *

Please indicate anything which might prevent independent completion of assessments.

Is the contact person the same as the referral source? *

Contact Person: *

First

Last

Relation to patient: *

Contact Person's Email: *

Contact Person's Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Contact Person's Phone Number: *

Is this a...

mobile
home
work line

Who will be expected to pay for the evaluation? If you intend to use insurance, please enter your information here now. *

Commercial Insurance
Private Pay
WV Medicaid
Medicare
Courts/DHHR, Other (add below)

*If WV Medicaid, we may need both the Medicaid ID and the Patient SSN before the evaluation can be scheduled. If court ordered, we will need to have the order BEFORE the evaluation will be scheduled. Please do not select private pay unless you do not have or do not intend to use insurance.

Other Payment Arrangement *

Please Explain

Primary Insurance Carrier: *

Policy Number *

Group Number:

Policy Holder's Name: *

First

Last

Policy Holder's Date of Birth: *

MM/DD/YYYY

Policy Holder's SSN: *

This is often needed for insurance verification.

Policy Holder's Relation to Patient: *

Medicaid or Medicare ID: *

This should be an ID number and is not usually the SSN

Medicaid or Medicare Type/Plan

Please indicate the Medicaid type or MCO (e.g., traditional Medicaid, Aetna Better Health, the Healthplan) or name of Medicare plan (e.g., Humana silver)

Is there more than one form of insurance? *

Answer Yes if you have two commercial insurances, commercial insurance with Medicaid secondary, or any combination of coverage. Please provide all insurance information.

Secondary Insurance Type *

Commercial
Medicaid
Medicare

Secondary Insurance Carrier: *

Secondary Policy Number *

Secondary Group Number:

Secondary Policy Holder's Name: *

First

Last

Secondary Policy Holder's Date of Birth: *

MM/DD/YYYY

Secondary Policy Holder's SSN: *

This is often needed for insurance verification.

Secondary Policy Holder's Relation to Patient: *

Secondary Medicaid or Medicare ID: *

This should be an ID number and is not usually a SSN

Secondary Medicaid or Medicare Type/Plan

Please indicate the Medicaid type or MCO (e.g., traditional Medicaid, Aetna Better Health, the Healthplan) or name of the Medicare Plan (e.g., Humana silver)

Any other pertinent information:

Provider/Advocate Referral

If you are a medical or mental health provider, case worker, attorney, probation officer, etc. you can use this abbreviated referral form. We will use the information provided to connect with the person being referred to complete their own full therapy or evaluation referral. If this is for a forensic evaluation, please complete the full evaluation referral form.

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Your Name *

First

Last

This form is for providers/advocates only. If you are seeking services for yourself or your child, please complete the full evaluation or therapy form

Your Email

Your Phone Number

Your connection to the person you are referring *

Your Practice/Agency/Organization *

Referral is for *

Evaluation
Therapy

The person being referred is *

An adult
A child

Client Name *

First

Last

Client Date of Birth *

Email address for Client or Parent/Guardian

Please provide client email so we may contact them to complete the full referral form.

Phone Number for Client or Parent/Guardian

Presenting Concerns: *

Please briefly describe the symptoms the client is experiencing and the service(s) requested.

Relevant Records

Click or drag files to this area to upload. You can upload up to 3 files.

Please attach any relevant records or information here.