Referral Form

Today's Date

Date

Services Requested*

Client's Full Name*

Client's Birth Date*

Date

Age*

Social Security Number (used to verify insurance)

Gender

Marital Status

Race/Ethnicity

Race/Ethnicity*

Primary language spoken in the home*

Ethnicity, cultural, and spiritual factors influence the way we perceive and interpret our world, ourselves, and our relationships. Some factors could include: age, values/beliefs, preferred language, communication needs, gender, sexual orientation, or relational factors. Please share any information regarding ethnicity, cultural, and spiritual background that may be helpful.*

School/Work (if applicable)

Client Address

Street Address

Street Address Line 2

CityState

Zip Code

Is there a Legal Guardian?*

YesNoNot Sure

Legal Guardian Full Name*

Legal Guardian Phone Number*

Please enter a valid phone number.

Does the Legal Guardian also live at the address above?*

YesNo

Legal Guardian Address*

Street Address

Street Address Line 2

CityState

Zip Code

Does the Legal Guardian share custody?*

YesNoNot Sure

Other Legal Guardian Full Name*

Other Legal Guardian Email*

example@example.com

Other Legal Guardian Phone*

Please enter a valid phone number.

LEGALLY Required Acknowledgement of Guardianship*

I acknowledge in the case of joint custody of a child both parents/guardians must sign a permission for treatment before the first visit. Each parent/guardian acknowledges that it is their responsibility to be in contact with their child's clinician regularly. Participation in treatment planning and therapy sessions is encouraged by all caregivers involved in the child's life.

Primary Phone

Please enter a valid phone number.

Secondary Phone

Please enter a valid phone number.

Is it OK to contact you via these addresses and phone numbers?

YesNo

Does the client have health insurance?

YesNo

Select Type of Insurance

Name of Health Insurance (Ex: Passport or BCBS)

Medicaid ID# (starts with 00 0r 100) or Private Insurance #

Is the client on medication?

YesNo

Please list all medications and prescribing providers.

	Medication	Dosage	Prescribing Provider	Provider Phone
1.
2.
3.

Do you have a primary diagnosis for which you are currently being treated? If yes, list diagnosis.

0/2000

Please list your primary concern related to mental health here (reason for seeking treatment):*

0/2000

Functional Impairment Rating Scale ( 1 = None, 5 = Severe)*

	1	2	3	4	5
Affective (Depression, mania, mood instability)
Anxiety (Panic, worry, anxiety, nightmares)
ADHD (Hyperactivity, impulsive)
Obsessions and Compulsions (Rituals,fear of contamination, excessive need for disorder)
Reality Construction and Thought Process (Delusions, hallucinations, paranoia)
Cognitive (Brain trauma, dementia, mental retardation
Social (Difficulty with positive social relationships, social isolation
Substance Abuse (Problematic use of drugs or alcohol)
Harm to Self or Others (suicidal ideation, intentional self-harm)
Appetite and Eating (Disturbance of appetite, anorexia, bulimia)
Sleep (Disturbance in sleep patterns)
Other Medical Conditions (Medical conditions that impact quality of life

Referral Source Full Name*

Referral Source Email

example@example.com

Referral Source Phone

Please enter a valid phone number.

Referral Source Address

Street Address

Street Address Line 2

CityState

Zip Code

If you have any additional information to submit, choose "Browse Files"

Submitter Full Name

Submitter Email

example@example.com