Counseling Referral Form

Electronic Communication Please check the box below to consent for Lilyfield to follow up with regarding this referral and scheduling via email. Please allow up to 20 minutes to complete this form. I understand that by completing this form I am consenting for Lilyfield to communicate with me via the email listed below regarding my referral and possible future scheduling of services

Client Name

First NameMiddle NameLast Name

Client date of birth

Parent/Guardian Name

Gender

Preferred Pronouns

Race

Ethnicity

Primary language spoken: We currently provide services in English only,

Religion

Number of Household Members:

Household Income

E-mail

example@example.com

Phone Number

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Referred by:

DHS Custody

DHS worker Name and Email if applicable

If Client is a Minor, please select the custody status

If anything other than N/A is selected above please list Custodial Parent's Name and Email

Please explain why you are requesting services at this time.

Preferred Days and Times (check all that apply)

Insurance Name

Insurance ID Number

Insurance name

Lilyfield location requested

Therapist requested

Additional Comments

Name of person completing this form

First NameLast Name

Relationship to Client