Counseling Referral Form

Counseling Referral Form

Fill out the form carefully for registration
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*

YesNo
DHS worker Name and Email if applicable*
If Client is a Minor, please select the custody status*

Sole CustodyJoint CustodyNon-Custodial ParentN/A (Parents are married or client is an adult)
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)*

MondayTuesdayWednesdayThursdayFriday8:30am-12:00pm12:00 pm-3:00 pmWait ListTelehealth
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*
Should be Empty: