Make A Family Connections Referral

Counseling/Evaluations

To begin the referral process, please complete the form below. If you have any questions or need assistance, please contact our referral line at 401-400-9186. Our intake coordinator will return your call ASAP. Insurance companies accepted:

  • • Neighborhood Health Plan of Rhode Island
  • • United Behavioral Health
  • • DCYF 005 Provider
  • • Blue Cross/Blue Shield RI
  • • Self Pay

Instructions: All fields are required unless otherwise noted as optional. If you have more than one client name you will have the opportunity to fill out additional forms once this form is submitted. Please be sure to include name, date of birth and insurance information for each child.

Family Connections Referral Form - Counseling/Evaluations
This form is for mental health counseling and evaluations.