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.

Information about Person Completing Referral
Name*

First NameLast Name
Referral Source Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Referral Patient Information
Is this a re-referral of a patient who was referred 6 months ago, if so, a new assessment is needed.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Last 4 of SSN
If unknown, add ZEROs
Email (Parent/Guardian)*
example@example.com
Phone Number*
Please enter a valid phone number.
Insurance Name*
Please enter insurance name
Insurance Number*
Please enter a valid and active insurance number
Current Diagnosis*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Individual and Parent/Guardian aware of this Referral?*

YesNo
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 cmarrero@leoclinc.care
Type of Services Needed (All services include individual and family treatment)*

Outpatient Therapy-VirtualOutpatient Therapy-In PersonOutpatient Therapy Virtual or In-Person and Medication Management ServicesIntensive Outpatient Program-Virtual
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
School Name *
Name of the School your child is in
Grade*
Educational Plan*

504 PlanIEP PlanRegular EducationI am not sure
If on an Educational Plan, what related services does this client have*

Social Work ServicesSpeech Pathology ServicesAutism ServicesReading/Writing InterventionParaprofessional ServicesI am not sureOther
Parent/Guardian Name*

First NameLast NameRelationship
Phone Number*
Please enter a valid phone number.
Email
example@example.com
What is the Parents Primary Language*
Please enter the language that the parent speaks
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
Individual Gender*

MaleFemaleOther
Individual Primary Language*

EnglishSpanishOther
Reason for Referral*
This must be a full description, please enter at the very least 2-3 sentences.
Current Medications*
This must be completed in full if the individual is taking medications
Select all applicable challenges below for the Individual referred (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.*
Time

Hour Minutes

AM/PM Option
Date

MonthDayYear
Date
Please verify that you are human*
Signature

Clear
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.
Date

MonthDayYear
Date
Signature

Clear
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
Should be Empty:

LEO Clinic Outpatient Behavioral Health Referral Form

LEO Clinic Staff Only