SAFE PLACE COUNSELING & CONSULTING LLC

SAFE PLACE COUNSELING & CONSULTING LLC

"Where our home is your home"
REFERRAL FORM
Please complete this form and send along with any available history or physical information on the individual. We will arrange an intake interview and determine eligibility for services.
RECIPIENT PERSONAL INFORMATION
DATE OF REFERRAL

MonthDayYear
Date
NAME*
DOB
AGE
GRADE (If Applicable)
GENDER
RACE
SS# (Optional)
MEDICAID #
INSURANCE PROVIDER
ADDRESS
PHONE*
ALTERNATE NUMBER
Email*
example@example.com
PARENT/GUARDIAN NAME (If Applicable)
SCHOOL/EMPLOYER (If Applicable)
PREFFERED LANGUAGE
NEED INTERPRETER: YES / NO
PRESENTING ISSUE(S)
PRIMARY CARE PSYSICIAN
PHONE#
DATE OF LAST HOSPITALIZATION

MonthDayYear
Date
IS THE RECIPIENT CURRENTLY ENROLLED WITH ANOTHER MENTAL HEALTH PROVIDER

YesNo
IF YES, PLEASE PROVIDE FACILITY NAME AND LAST DATE SEEN
ARE THEY CURRENTLY TAKING MEDICATION FOR MENTAL HEALTH ISSUES

YesNo
REFFERED BY
CONTACT NUMBER
I do understand that this form is only a referral to receive services from Safe Place Counseling & Consulting LLC and it does not guarantee enrollment into the program. Safe Place does not provide any monetary compensation for client enrollment into services. My signature on this form is an attestation that I did not receive any compensation from Safe Place Counseling & Consulting LLC and its affiliates to enroll in services.
Client Signature

Clear
Date

MonthDayYear
Date
Visit us www.safeplacecounseling.org
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