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100 Front St Suite 401, Worcester, Massachusetts, 01608
info@westfieldbh.com
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Refer
Home
Contact
Resources
Accepted Insurance
Mental Health Resources (Blog)
Our Providers
Patient FAQs
Request an Appointment
About
Services
Refer
Call Us
(508) 644-0446
New Patient
Referral Form
Westfield Behavioral Health is currently accepting new patients.
Please complete the form below to refer a patient for psychiatric evaluation and or medication management.
Referring Provider Information:
First Name
Last Name
Email
Phone Number
Organization/Practice (optional)
Patient Information
First Name
Last Name
Date of Birth
Email
Phone Number
Home Address
Apartment/Suite (Optional)
City
State
Zip Code
Gender
Male
Female
Non-binary
Prefer not to answer
Other
Primary Language
English
Spanish
Other
Referral Information
Reason for Referral
Psychiatric Diagnosis (if known) (Optional)
Current Psychiatric Medications
Relevant Medical History (Optional)
Safety Concerns (Optional)
Suicidal ideation
History of suicide attempt
Self-injurious behavior
Homicidal ideation
Psychosis
None
Presenting Concerns
ADHD / Attention Difficulties
Anxiety
Depression
Bipolar Disorder
Mood Instability
PTSD / Trauma
OCD
Panic Attacks
Sleep Problems / Insomnia
Substance Use
Alcohol Use Disorder
Self-Harm
Anger / Irritability
Impulsivity
Social Difficulties
School or Academic Concerns
Behavioral Problems
Medication Evaluation
Medication Management
Psychiatric Evaluation
Hospital or Residential Discharge Follow-up
Other:
Additional Information
Send
