Counseling in Place referral form
If you would like to refer someone to our program, please fill out our form below.
Client Information
Client's Primary Language Spoken*
*
Please Select
English
Spanish
Other
Language if Other
Client Name
*
First Name
Last Name
Date of Referral
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
-
Area Code
Phone Number
Client's Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Ethnicity
Please Select
Asian
Black
Hispanic/Latino
American Indian/Alaska Native
Hawaiian/Pacific Islander
White
Other
Ethnicity if Other
Gender
*
Please Select
Male
Female
Emergency Contact Information
Emergency Contact Name
First Name
Last Name
Relationship
Contact Phone Number
-
Area Code
Phone Number
Alternate Contact Phone Number
-
Area Code
Phone Number
Referral Source
(Individual completing this form.)
Referral Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
Relationship to client
Agency
Is client aware of the referral?
*
Please Select
Yes
No
If no, please explain why the client was not informed of the referral.
*
Should the referral source accompany the client on initial visit?
Please Select
Yes
No
If yes, please explain why the referral source needs to accompany the client during the first visit.
*
Presenting Problem
Reason for Referral / Goal
Past / Current Mental Health Treatment
Significant Health Problems / Medications
Does the senior see a therapist / psychiatrist?
Please Select
Yes
No
If yes, please explain why the client is being referred if they are already receiving services elsewhere.
*
Provider Name
Provider Phone Number
-
Area Code
Phone Number
Is the client able to attend office appointments?
*
Please Select
Yes
No
Please provide additional details:
*
Is the client able to access virtual counseling independently?
*
Please Select
Yes
No
Please provide additional information:
*
Is the client being followed by DHHS staff?
Please Select
Yes
No
Staff Name
Staff Phone Number
-
Area Code
Phone Number
Please list other agencies involved with the client:
Current substance abuse/treatment?
Please Select
Yes
No
Unknown
Insurance
*
Medicare
Medicaid
CareFirst
United Healthcare
Aetna
Kaiser
Cigna
Uninsured
Unknown
Client insurance
*
Please Select
United Healthcare
Aetna
Kaiser
Cigna
Medicare
Medicaid
Not Insured
No answer
Insurance Member ID
*
Secondary Insurance
*
Secondary Insurance Member ID
*
History of the Following
Suicide attempts?
*
Please Select
Yes
No
Unknown
Violent behavior?
*
Please Select
Yes
No
Unknown
Weapons in the house?
*
Please Select
Yes
No
Unknown
Pets in house?
*
Please Select
Yes
No
Unknown
Please describe pets:
Active bedbug infestation within the last year?
*
Please Select
Yes
No
Unknown
Additional information:
Attach supporting documents here.
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