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LEADING LIGHT BEHAVIORAL HEALTH INC
Client Referral Form
Today's Date
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Minutes
AM
PM
AM/PM Option
Referral Information
Please tell us who referred you. (If you are the referrer completing the form please put your name here)
Were you referred by any of the following state agencies?
*
Please Select
DYS
DCF
DTA
DMH
SSA
Probation
Does not apply
Please provide the information of the state agency Case Worker/Social Worker
Reason for Referral
*
Give as much detail as possible.
Service Type
*
Individual Counseling
Family Counseling
Couples Counseling
Child/Adolescent Therapy
Anger Management
Substance Abuse Evaluation
Bariatric Evaluation
Mental Health Evaluation
Dialectical Behavior Therapy (DBT)Program
Community Support Program (CSP)
CSP for Justice-Involved (CSP-JI)
CSP – Tenancy Preservation Program (CSP-TPP)
CSP for Homeless Individuals (CSP-HI)
Other
Group Selection
Adolescent Group
Art Therapy Group
DBT Group
Trauma Group
Couples Group
Adolescent Group
Psychoeducation Group
Substance Use Group
Court Mandated Training
Expressive Arts Group
For Group therapy
Preferred top 2 Providers
Edwing
Myriam
Sere
Greg
Jessica
Laurie
Guan
Lori
Mary
Robyn
Practice Providers
Please indicates the days and times you are available to be seen (also subject to provider availability we will do our best to accommodate)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
8am - 10am
10am -12pm
12pm -2pm
2pm - 4pm
4pm - 6pm
6pm-8pm
Referral Concern
*
Anxiety
Depression
Grief
Mood disorder
Personality Disorder
Weight Management
Trauma
Post/Pre Incarceration
Perinatal
Gender Dysphoria
Other
Client Details
Client Name
*
First Name
Middle Name
Last Name
Client Phone Number
*
Please enter a valid phone number.
Client Email: (Please be advised we need to send initial paperwork via email. Generic emails i.e example@ataskthepatient.com may delay patients start).
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Is the client a minor (under 18)
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
Please Select
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District of Columbia
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Hawaii
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
City in Massachusetts
Please Select
• Abington, MA
• Acton, MA
• Acushnet, MA
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• Wenham, MA
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• West Brookfield, MA
• West Chatham, MA
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• West Falmouth, MA
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• West Springfield, MA
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• West Tisbury, MA
• West Wareham, MA
• West Yarmouth, MA
• Westborough, MA
• Westfield, MA
• Westford, MA
• Westminster, MA
• Weston, MA
• Westport, MA
• Westwood, MA
• Weymouth, MA
• Whately, MA
• Whitinsville, MA
• Whitman, MA
• Wilbraham, MA
• Williamsburg, MA
• Williamstown, MA
• Wilmington, MA
• Winchendon, MA
• Winchester, MA
• Windsor, MA
• Winthrop, MA
• Woburn, MA
• Woods Hole, MA
• Worcester, MA
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• Yarmouth Port, MA
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Gender Identity
*
Male
Female
N/A
Other
Pronouns
*
Race
*
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Ethnicity
*
Hispanic
White alone, non-Hispanic
Black or African American alone, non-Hispanic
American Indian and Alaska Native alone, non-Hispanic
Asian alone, non-Hispanic
Native Hawaiian and Other Pacific Islander alone, non-Hispanic
Some Other Race alone, non-Hispanic
Multiracial, non-Hispanic
Policy Holders Name and DOB
*
IF YOU ARE NOT THE SUBSCRIBER OF THE INSURANCE POLICY PLEASE ENTER THE SUBSCRIBERS INFROMATION
Relationship to Policy Holder
*
Self, Wife, Husband, Mother, Father, etc.
Insurance Number
*
Insurance Type
*
Aetna
Allways Health Partners
Beacon
Blue Cross Blue Sheild
BMC Healthnet
Cigna
Fallon Health
Harvard Pilgrim
Optum
Public Health Plans
Senior Whole Health
Tricare
Tufts Public
Tufts Commercial
Unicare
United Health Care
Mass Health
MBHP (6 month wait)
Medicaid
Client History
Diagnosis (if any)
History of Seizures?
Please Select
Yes
No
History
*
History of Trauma
History of Auditory Hallucinations
History of Suicidal or Homicidal Thoughts
History of Violence
History of Suicide or Homicidal attempts
History of Visual Hallucinations
None
Other
Please explain all the boxes you checked above.
*
Type N/A if it does not apply.
History of hospitalizations?
*
Yes
No
History of hospitalizations details...
*
Please provide locations, dates, reason for hospitalization and treatment provided.
History of Substance Use
*
Yes
No
History of Substance Use details...
*
Provide details of history of substance use. Please provide current and past use. What substance used, frequency, intensity, and duration usage.
Current or Past Prescriber or relevant provider
Please provide name, phone number and address for the provider.
List all Medication, use, and dose. Please let us know of all Allergies
*
Please provide name of medications, dosage, and reason.
Please do not skip for prescriber referrals. Please select all that have been completed and attached.
Release of Information
Comprehensive Assessment
Medication List
Other
Legal
Select this box option if you are over 18 and skip this section.
18+ skip this section
Who is the legal guardian?
First Name
Last Name
Relationship to Child
Guardian 2
First Name
Last Name
Relationship to child
Is there a court order or restraining order in place? (Please upload a copy)
*
Yes
No
Other
Is there a state agency involved?
Yes
No
Other
If there is a state agency involved, please provide agency type, contact person, and contact information.
DCF, Court, DYS, DMH, etc.
Additional comments
Signature
*
Files: Please attach a copy of your insurance card. Front and back. Hospital records, discharge forms, medication list, etc.
Browse Files
Along with a release and any additional necessary documents.
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