We are currently offering both in-person & telehealth options at both locations.

We ask that if you have been exposed to someone who has tested positive, or if you are experiencing a fever, or symptoms which might be Covid-related, that you use telehealth until you are feeling well or test negative.

Masks are required for in-office appointments.

Please call 304-241-1766 for further information.

Mountaineer Psychological Services

Referrals

Referral Forms

therapy referral form (PDF)

therapy referral form (online)

evaluation referral form (PDF)

evaluation referral form (online)

therapy referral form (PDF)

therapy referral form (online)

evaluation referral form (PDF)

evaluation referral form (online)

Therapy Referral Form

- Step 1 of 6

Patient Name *

First

Last

Date of Birth *

MM/DD/YYYY

Sex

Male
Female

Age

SSN *

Referred by:

First

Last

Relation to Patient:

Referral Contact Info

Fax

Patient Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Telephone Number *

Is this a...

mobile
home
work line

Patient Email *

Payment Choice

Private Pay
Insurance (information required below)

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 *

Secondary Insurance?

Secondary Insurance Policy Number *

Secondary Insurance Group Number *

Secondary Policy Holder's Name *

First

Last

Secondary Policy Holder's Date of Birth *

MM/DD/YYYY

Secondary Policy Holder's Social Security Number *

Secondary Policy Holder's Relation to Patient *

Please briefly describe presenting concern(s): *

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

Please list approximate dates & reasons:

Is the patient being treated by any mental health professional or taking any psychiatric medications now? *

Has patient been HOSPITALIZED for mental health reasons? *

Please list approximate dates & reasons:

Has the patient ever had a psychological EVALUATION?

Please list approximate dates & reasons:

Does the patient have any significant MEDICAL issues? *

Please describe:

How did you hear about our clinic?

Preferred Location

Morgantown
Bridgeport
Either

Clinician Requested:

Morgantown: Jennifer Myers, PhD
Morgantown: Stacey Crandall, LPC
Morgantown: Amy Zeiders, LICSW
Morgantown: Ron Satterfield, LCSW
Morgantown: Alissa Gren, LICSW
Morgantown: Ellis Moran MA
Morgantown: Thomas Ewell MS
Morgantown: Ric Renquest MA, LPC
Bridgeport: Jennifer Myers, PhD
Bridgeport: Jennifer Adams, MA, LPC
Bridgeport: Thomas Ewell MS
First Available
No Preference

Evaluation Referral Form

- Step 1 of 8

Patient Name *

First

Last

Referral Source

Referral Source Contact Info

Relation to Patient

Agency

WV DHHR
Probation
CPS
Other: add below

Other Agency:

Patient Date of Birth *

MM/DD/YYYY

Sex

Male
Female

Age

Social Security Number *

Medicaid ID Number

Patient Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Telephone Number *

Is this a...

mobile
home
work line

Email Address *

Is this evaluation court-ordered?

Please attach a copy of the court order

Click or drag a file to this area to upload.

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

Purpose of Evaluation *

What question(s) are to be answered via the evaluation?

Please briefly describe the patient's presenting concern(s):

Abuse/ Neglect
Truancy
Substance Abuse
Parental Fitness
Other: please add below

Other:

Please describe the details of the presenting concern: *

Please attach any available records or send them to: office @mountaineerpsyc.com prior to the evaluation.

Click or drag a file to this area to upload.

PREVIOUS mental health treatment? *

Please describe:

CURRENT mental health treatment or medication? *

Please describe:

Prior HOSPITALIZATION for mental health reasons? *

Please list approximate dates & reasons:

Any current/ pending LEGAL charges? *

Please describe:

Does the person have any limitations (literacy issues, communication problems, physical disabilities, etc.) which might need to be considered for the evaluation? *

Please describe:

Contact Person (if not the patient):

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 pay for the evaluation?

private pay
insurance
WV Medicaid
Other (add below)

*If WV Medicaid, we will 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.

Other Payment *

Primary Insurance Carrier: *

Policy Number *

Group Number:

Medicaid ID:

Policy Holder's Name: *

First

Last

Policy Holder's Date of Birth: *

MM/DD/YYYY

Policy Holder's SSN: *

Policy Holder's Relation to Patient: *

Any other pertinent information: