LEADING LIGHT BEHAVIORAL HEALTH INC
Client Referral Form
Today's Date
*
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Referral Information
If "None of the Above" Please tell us who referred you. (If you are the referrer completing the form please put your name here)
Reason for Referral
*
Give as much detail as possible.
Please Select The Service You Need
*
Anger Management Training
Healing 2'getha Couples Retreat (Now Accepting Applications)
Couples Group Therapy
Medication Management
Family & Domestic Violence-Waitlist
Parenting Workshops-Waitlist
Court Ordered Psych Evaluations
Case Management
School Based Services
Skill Development Program
Community Support Services
In-Home Behavioral Services
Mobile Crisis Intervention
Therapeutic Mentoring
Intensive Care Coordination
Transition Services
Group Therapy
Behavioral Health Urgent Care Services
Medication Management
Family Training Support
Other
Group Selection
Adolescent Group
Art Therapy Group
General DBT Group (on hold)
BIPOC DBT Group (on hold)
Trauma Group
Couples Group
Adolescent Group
Psychoeducation Group
Substance Use
Court Mandated Training
For Group therapy
Preferred top 2 Providers
Edwing
Gregorit
Kerri
Tiffany - Has Openings
Ilannah - Has Openings
Shannon - Has Openings
Kanisha - Has Openings
Katie - Has Openings
Leah - Has Openings
Jasmin - Has Openings
Robert - Has Openings
Myriam - Has Openings
Prescriber - Has Openings
Substance Use Services
Practice Providers
Please indicates the days and times you are available to be seen (also subject to provider availability we will do our best to accommodate)
Monady
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
8am - 10am
10am -12pm
12pm -2pm
2pm - 4pm
4pm - 6pm
6pm-8pm
Referral Concern
*
Anxiety
Depression
Mood disorder
Trauma
Post/Pre Incarceration
Perinatal
PTSD
Anger/Rage
Marital/Relationship Problems
Other
Client Details
Client Name
*
First Name
Middle Name
Last Name
Client Phone Number
*
Please enter a valid phone number.
Client Email: (Please be advised we need to send initial paperwork via email. Generic emails i.e example@ataskthepatient.com may delay patients start).
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Is the client a minor (under 18)
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Gender Identity
*
Male
Female
N/A
Other
Pronouns
*
Race
*
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Ethnicity
*
Hispanic
White alone, non-Hispanic
Black or African American alone, non-Hispanic
American Indian and Alaska Native alone, non-Hispanic
Asian alone, non-Hispanic
Native Hawaiian and Other Pacific Islander alone, non-Hispanic
Some Other Race alone, non-Hispanic
Multiracial, non-Hispanic
Policy Holders Name and DOB
*
IF YOU ARE NOT THE SUBSCRIBER OF THE INSURANCE POLICY PLEASE ENTER THE SUBSCRIBERS INFROMATION
Insurance Number
*
Insurance Type
*
Aetna
Allways Health Partners
Beacon
Blue Cross Blue Sheild
BMC Healthnet
Cigna
Fallon Health
Harvard Pilgrim
Optum
Public Health Plans
Senior Whole Health
Tufts Public
Tufts Commercial
Unicare
United Health Care
Mass Health
MBHP (6 month wait)
Medicaid
Client History
Diagnosis (if any)
History of Seizures?
Please Select
Yes
No
History
*
History of Trauma
History of Auditory Hallucinations
History of Suicidal or Homicidal Thoughts
History of Violence
History of Suicide or Homicidal attempts
History of Visual Hallucinations
None
Other
Please explain all the boxes you checked above.
*
Type N/A if it does not apply.
History of hospitalizations?
*
Please provide locations, dates, reason for hospitalization and treatment provided.
History of Substance Use
*
Provide details of history of substance use. Please provide current and past use. What substance used, frequency, intensity, and duration usage.
Current or Past Prescriber or relevant provider
Please provide name, phone number and address for the provider.
List all Medication, use, and dose. Please let us know of all Allergies
*
Please provide name of medications, dosage, and reason.
Please do not skip for prescriber referrals. Please select all that have been completed and attached.
Release of Information
Comprehensive Assessment
Medication List
Other
Legal
Select this box option if you are over 18 and skip this section.
18+ skip this section
Who is the legal guardian?
First Name
Last Name
Relationship to Child
Guardian 2
First Name
Last Name
Relationship to child
Is there a court order or restraining order in place? (Please upload a copy)
*
Yes
No
Other
Is there a state agency involved?
Yes
No
Other
If there is a state agency involved, please provide agency type, contact person, and contact information.
DCF, Court, DYS, DMH, etc.
Additional comments
Signature
*
Files: Please attach a copy of all court orders.
Browse Files
Along with a release and any additional necessary documents.
Cancel
of
Save
Submit
Clear Form
Print Form
Should be Empty: