Lionheart Family Services Referral Form

Lionheart Family Services Referral Form

Complete the following for individual being referred:
Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Birth Date*

MonthDayYear
Insurance (OH Medicaid, or Managed Care Plan)*

Buckeye Health PlanCaresourceMolina HealthcareUnitedhealthcare Community PlanAnthem MedicaidOH Medicaid (not currently enrolled in a managed care plan)OH RiseHumana Healthy Horizons*AmeriHealth Caritas*
Concerns (check all that apply)*

Academic, or attendance problemsAngry outburst, rage, or tantrumsAnxious, fearful, nervous, restlessConflict with authorityDefiant, refusing to follow rulesDepressed, sad, tearfulDisruptive, attention seekingDoes not accept responsibility for behaviorFighting, arguingGrief/bereavementImpulsive/risky behaviorsInability to express feelingsLow self-esteem, poor social skillsNo eye contact, unkempt, disheveledPoor peer relationships/conflictsSexually inappropriate behaviorStealing, or lyingVerbally abusive, or aggressive