LEO Clinic Outpatient Behavioral Health Referral Form

LEO Clinic Outpatient Behavioral Health Referral Form

Thank you for taking time to complete our on-line referral form. Once submitted, we will reply to via e-mail with a confirmed assessment date and time that the parent/guardian has chosen. If this is a school-based referral, it can take up to 2-3 weeks before the client is seen in the school.
- Name of Person making referral*
  
  First NameLast Name
- Name of Agency *
- Relationship to Patients*
- Referral Source Email*
  example@example.com
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Name of Patient*
  
  First NameLast Name
- Date of Birth*
  
  MonthDayYear
- Patient Insurance Name*
  Please enter insurance name
- Patient Insurance Number*
  Please enter a valid and active insurance number
- Last 4 of SSN
  If unknown, add ZEROs
- Patient Current Home Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Patient Primary Language*
  
  EnglishSpanishOther
- Patient Gender*
  
  MaleFemaleOther
- Parent/Guardian Information
- Parent/Guardian Information*
  
  First NameLast Name
- Parent/Guardian Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Email (Parent/Guardian)*
  example@example.com
- Parent/Guardian Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Father/Guardian Name*
  
  First NameLast Name
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Behavioral Health Condition Management
- Behavioral Health Symptoms/Conditions*
  
  ADHD/ADDAlzheimer's DiseaseAnxietyAutismBipolar Affective DisorderDementiaDepressionEating DisorderPhobia(s)Post Traumatic Stress DisorderPsychosisSubstance Useother
- Behavioral Management Strategies*
  
  ActivityAbstinence from SubstancesAdequate RestCommunity ResourcesComplementary Therap(ies)Coping StrategiesCounselingEducation SystemExerciseMedication TherapyOptimal Nutrition IntakeSupport GroupSupport System
- Behavioral Health Self-Management Outcome*
- Behavioral Health Comment*
- Previous Mental Health Treatment*
  
  NoneCase ManagementCounselingDay TreatmentElectric Compulsive Therapy (ECT)Group TherapyInpatient TreatmentMedicationOutpatient TreatmentPartial Hospitalization ProgramPsychiatristPsychologistNot Applicable
- Previous Mental Health Treatment*
- Current Mental Health Treatment*
  
  NoneCase ManagementCounselingDay TreatmentElectric Compulsive Therapy (ECT)Group TherapyInpatient TreatmentMedicationOutpatient TreatmentPartial Hospitalization ProgramPsychiatristPsychologistNot Applicable
- Previous Mental Health Treatment*
- Substance History
- Substances Used (select all that apply):*
  
  AlcoholCannabis / MarijuanaPrescription medications (misuse)Opioids / PainkillersCocaine / StimulantsHallucinogens (LSD, mushrooms, etc.)InhalantsNicotine / VapingNo Known Use
- Age of First Use:*
- Frequency of Use (current):*
- Impact of Use:*
  
  No reported impactSchool performance issuesFamily conflictLegal involvementMental health symptoms (anxiety, depression, psychosis)Physical health concernsPeer/social issues
- Substance Abuse Treatment / Support History:*
  
  NoneOutpatient counselingIntensive outpatient program (IOP)Inpatient / detoxMedication-assisted treatment (MAT)Recovery support groups (AA/NA/SMART)
- Is this a School-Based Therapy Referral?*
  
  YesNo
- Which LEO Clinic School-Based Clinic, if not school-based referral choose N/A: Please note, it takes 3-4 Weeks for a school-based referral to be seen in school from the date of the student's initial intake appointment *
  If the school is not listed, this means we are not in network with your client's school. If you are intereted we can add your school to our network, e-mail mdelacruz@leoclinc.care
- Type of Services Needed (Choose One Only)*
  
  Outpatient Therapy-VirtualOutpatient Therapy-In PersonOutpatient Therapy Virtual or In-Person and Medication Management ServicesIntensive Outpatient Program-VirtualMedication Management OnlyADHD AssessmentAutism Evaluation
- Academic History
- School Name *
  Name of the School your child is in
- Current Grade*
- Grades Skipped*
- Grades Held Back*
- Academic Performance*
- Academic Strengths*
  
  Per parent report, the child demonstrates the following academic weaknesses Strong Reading and Comprehension Skills – demonstrates advanced vocabulary, reading fluency, and ability to understand and interpret texts. Reading / Comprehension – enjoys reading, understands stories, remembers details.Per parent report, the child demonstrates the following academic weaknesses Mathematical Reasoning – shows problem-solving ability, logical thinking, and strength in computation and abstract reasoning. Math / Problem Solving – strong in numbers, computation, or logical reasoning.Per parent report, the child demonstrates the following academic weaknesses Writing and Communication – able to clearly express ideas in writing, organize thoughts, and use appropriate grammar and structure. Writing / Communication – expresses ideas clearly in writing, organizes work well.Per parent report, the child demonstrates the following academic weaknesses Critical Thinking and Analysis – demonstrates ability to compare, evaluate, and synthesize information across subjects. Creativity / Curiosity – enjoys projects, experiments, or asking thoughtful questions.Per parent report, the child demonstrates the following academic weaknesses Creativity and Innovation in Learning – excels in generating original ideas, applying knowledge in unique ways, and demonstrating curiosity in academic exploration. Focus / Work Habits – completes assignments, stays organized, shows persistence.
- Academic Weaknesses*
  
  Per parent report, the child demonstrates the following academic weaknesses Reading Difficulties – struggles with reading fluency, comprehension, or remembering details.Per parent report, the child demonstrates the following academic weaknesses Math Challenges – difficulty with computation, word problems, or applying logical reasoning.Per parent report, the child demonstrates the following academic weaknesses Writing / Organization – has trouble expressing ideas clearly in writing, spelling, or organizing written work.Per parent report, the child demonstrates the following academic weaknesses Attention / Focus – struggles with staying on task, completing assignments, or following multi-step directions.Per parent report, the child demonstrates the following academic weaknesses Test-Taking / Academic Confidence – experiences anxiety during tests, difficulty recalling information, or low confidence in school performance.
- Likes about School*
  
  Per parent report, the child enjoys the following aspects of school Friends / Socializing – enjoys being with peers, recess, group activitiesPer parent report, the child enjoys the following aspects of school Favorite Subjects – has interest in a specific subject (e.g., math, reading, science, art).Per parent report, the child enjoys the following aspects of school Teachers / Relationships with Adults – feels supported or connected to teachers or staff.Per parent report, the child enjoys the following aspects of school Extracurriculars / Specials – enjoys sports, music, art, clubs, or other special programs.Per parent report, the child enjoys the following aspects of school School Environment / Routine – likes the structure, classroom setup, or being part of a community.
- Dislikes about School*
  
  Per parent report, the child enjoys the following aspects of school Academic Subjects – expresses frustration with reading, math, or other challenging subjects.Per parent report, the child enjoys the following aspects of school Homework / Assignments – resists completing homework or feels overwhelmed by workload.Per parent report, the child enjoys the following aspects of school Tests / Performance Pressure – dislikes quizzes or exams due to anxiety or low confidence.Per parent report, the child enjoys the following aspects of school Social Difficulties – struggles with peers, feels isolated, or reports bullying/peer conflict.Per parent report, the child enjoys the following aspects of school Rules / Structure – dislikes classroom rules, transitions, or the overall routine of school.
- Special Education Needs*
  
  AutisticCommunication ImpairmentDevelopmental DelayEmotional ImpairmentGiftedIndividualized Education PlanIntellectual ImpairmentNuerological ImpairmentPhysical ImpairmentSensory ImpairmentSpecific Learning DisabilityTraumatic Brain InjuryNone
- 504 Plan in Place*
- What is the Parents Primary Language*
  Please enter the language that the parent speaks
- Current Medications*
  This must be completed in full if the individual is taking medications
- Reason for Referral (check all that apply)*
  
  Ability to avoid dangers/hazardsAngerAnxietyCommunity Linkage of ServicesDaily living skillsDepressionGriefHousingHygieneImpulsive BehaviorsJuvenile Justice/Court InvolvedLife SkillsMaintaining personal affairsMedication EducationNutritionalPhobia/sPRTF/Hospital DischargeSafe living situationSchool behaviorSelf-Advocacy SkillsSelf HarmSeparation IssuesSocial SkillsSubstance UseSustainable employmentTraumaTruancyWhole Health/WellnessYouth to Young Adult TransitionOther
- Name of Previous Treatment Provider*
- Last Hospitalization and Reason for Hospitalization, if any.*
- Please verify that you are human*
- Signature
- Rate your overall experience with LEO Clinic
- Upload Discharge Summary, Referrals Made, IEP/504 Medication List etc
  
  Upload 504/IEP/
  Cancelof
- Copy of Release of Information or Consent form authorizing this referral
  
  Cancelof
- LEO Clinic Staff Only
  
  If the referral is denied, LEO Clinic Staff will reply to you with the following: In these cases of refusal the person requesting services must be notified either verbally or in writing. If the notification is done verbally, then this verbal notification must be documented here. Only requests for services that are provided by the clinic need to be documented if such a request for service is denied. The notification must include the reason for refusal and recommendations for more appropriate treatment services. Refusal for services will not be based on the client’s place of residence as we provide virtual treatment. The referral information, and the documentation of refusal notification will be maintained by the clinic in a confidential manner similar to that of client case records, retained for at least seven years, destroyed by either shredding or incineration, and given to the Department or a court of competent jurisdiction if the clinic ceases operation.
- LEO Clinic Staff Name assigned to the referral
  
  First NameLast Name
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Date
  
  MonthDayYear
  Date
- Signature
- This referral has been denied due to blanks. I recommend that the client to receive more appropriate treatment services for blank first before entering outpatient treatment.
- Type a question
- Type a question
- If on an Educational Plan, what related services does this client have*
  
  Social Work ServicesSpeech Pathology ServicesAutism ServicesReading/Writing InterventionParaprofessional ServicesI am not sureOther
- Is Individual and Parent/Guardian aware of this Referral?*
  
  YesNo
- Patient Current Diagnosis*
- Program Needed*
  
  Outpatient Behavioral HealthSchool-Based TreatmentChild/Adolescent Outpatient ServicesYouth to Young Adult Transition
- School District (Hartford, Windsor Locks, East Hartford, etc) *
  Please enter the District your child is in
- Educational Plan*
  
  504 PlanIEP PlanRegular EducationI am not sure
- Parent/Guardian Name*
  
  First NameLast NameRelationship
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Is this a re-referral of a patient who was referred 6 months ago, if so, a new assessment is needed.
- Specify service Individual is considering*
  
  Case Management (CM)Family Therapy (Mental Health ONLY)Group Therapy (Mental Health ONLY)Individual Therapy (Mental Health ONLY)Intensive Case Management (ICM)Medication Case ManagementPsychiatric Treatment (needs secondary service)Supported Employment (Mental Health ONLY)**Substance Use servicesPrimary Care ServicesDental Care Services
- Date of Hospitalization
  
  MonthDayYear
  Date
- Time
  
  Hour Minutes
  
  AM/PM Option
- Reason for Referral*
  This must be a full description, please enter at the very least 2-3 sentences.
- Email
  example@example.com
- Should be Empty:

LEO Clinic Outpatient Behavioral Health Referral Form

Parent/Guardian Information

Behavioral Health Condition Management

Substance History

Academic History

LEO Clinic Staff Only