Group Only Referral Form and Provider Agreement

Client Name*

First Last

Date of Birth*

Client Phone*

Client email*

Client Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Provider Name*

First Last

Provider Phone*

Provider Fax

Provider Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Client Insurance*

Insurance ID*

Name of group(s) client is being referred to*

I am the primary (Choose one) for the client referred to group treatment at Northwest ADHD Treatment Center.*

Consent*

Provider agrees

I understand that by completing this form only, my client is not eligible to meet with a Northwest ADHD Treatment Center provider for individual therapy, medication management, ADHD assessment, or other services outside of group therapy. I understand that if I wish to refer my client for other services, a separate referral form for those services is required. I understand that other services at Northwest ADHD Treatment Center may have significant wait times before services may become available for my client.

As the primary provider for this client, I agree that I will:

1. Assume full clinical responsibility for this client, and acknowledge that Northwest ADHD Treatment Center providers are not responsible for my client’s care outside of group therapy.

2. Handle or provide backup services to manage client clinical emergencies. I will inform my client that Northwest ADHD Treatment Center is not the appropriate resource for any clinical emergencies that may arise.

3. Submit this form to Northwest ADHD with relevant clinical records, including a valid release of information for mutual coordination of care, the most recent progress note and clinical assessment.

4. Inform and consult with Northwest ADHD group providers as appropriate, and especially if my client experiences significant and worsening symptoms.

5. Inform my client that they must be located in the State of Oregon during all group sessions, and that all groups are currently taking place via telehealth, and will continue to for the foreseeable future.