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
Should the referral source accompany the client on initial visit?
Please Select
Yes
No
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
Provider Name
Provider Phone Number
-
Area Code
Phone Number
Is the client able to attend office appointments?
*
Please Select
Yes
No
If 'no,' please explain:
• Is the client able to access virtual counseling independently?
*
Please Select
Yes
No
If 'no,' please explain:
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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