Referral Form

Today's Date

Date

Services Requested

Client's Full Name

Client's Birth Date

Date

Age

Client Social Security Number (used to verify insurance)

Gender

Marital Status

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?

Legal Guardian Full Name

Legal Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Does the Legal Guardian also live at the address above?

Legal Guardian Address

Street Address

Street Address Line 2

CityState

Zip Code

Does the Legal Guardian share custody?

Other Legal Guardian Full Name

Other Legal Guardian Email

example@example.com

Other Legal Guardian Phone

Please enter a valid phone number.Format: (000) 000-0000.

LEGALLY Required Acknowledgement of Guardianship

Primary Phone

Please enter a valid phone number.Format: (000) 000-0000.

Secondary Phone

Please enter a valid phone number.Format: (000) 000-0000.

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

Does the client have health insurance?

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?

Please list all medications and prescribing providers.

Rows	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)

Rows	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.Format: (000) 000-0000.

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