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LEADING LIGHT BEHAVIORAL HEALTH INC
New Client Contact Form
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Contact Form
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?
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DYS
DCF
DTA
DMH
SSA
Probation
Does not apply
Please provide the information of the state agency Case Worker/Social Worker
Reason for Referral
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Give as much detail as possible.
Service Type
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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)
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Client Details
Client Name
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First Name
Middle Name
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Client Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Client Email: (Please be advised we need to send initial paperwork via email. Generic emails i.e example@ataskthepatient.com may delay patients start).
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example@example.com
Date of Birth
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Street Address
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Street Address
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City
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Insurance information
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
Blue Cross Blue Shield
BMC Healthnet
Cigna
Fallon Health
Harvard Pilgrim
Mass General Brigham
Mass Health
MBHP
Medicaid
Medicare
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United Health Care
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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
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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