Referral Form

LifeConnect Health Referral Form
Welcome! Please choose the state of residence for the member you are referring:
From where are you referring this member? TN
From where are you referring this member? VA
From where are you referring this member? NM
From where are you referring this member? MN
From where are you referring this member? NC
From where are you referring this member?
- Your (referrer's) Name
- Your Phone:
  Please enter a valid phone number.Format: (000) 000-0000.
- Your Email:
  
  Confirmation EmailPlease re-type your email address to confirm that it is correct.
- Will you as the referrer be present (physically) to assist this individual at their initial assessment?
- Do you have the name of the person who will be scheduling and attending the assessment with this individual?
- Do you have the contact information of someone we can contact to find out?
- Please Enter as much contact information as is available for this person:
  
  First NameLast Name
- {pleaseEnter}'s Phone:
  Please enter a valid phone number.Format: (000) 000-0000.
- {pleaseEnter}'s Email:
  example@example.com
- Relation to {membersName}:
  To your best understanding

Member's Name:

First NameLast Name
Member's preferred name if different:
Member's Social Security Number
eg: 123-12-1234
Member's Date of Birth

MonthDayYear
Date
Member's Sex
Member's Marital Status
Member's Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Member's Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email where we can reach {membersName}:
example@example.com
Member's Preferred Language / Mode of Communication:
Member's Hearing Status:
Address where {membersName} can receive their tablet:

Street Address

Street Address Line 2

CityState

Zip Code
Does {membersName} also reside at this address?
Member's Residential Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter Primary Care Provider Information if available:

First NameLast Name
PCP Phone
Please enter a valid phone number.Format: (000) 000-0000.

Reason for Referral of {membersName}:
Services Requested
Describe in detail {membersName}'s current condition and symptoms
{membersName}'s Treatment History
Diagnosis

Does {membersName} have a Conservator?
Conservator's Name:

First NameLast Name
Conservator's Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Leave the following questions blank if they do not apply to the member you are referring. You're almost done!
Psychiatrist's Name:

First NameLast Name
Psychiatrist's Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Therapist's Name:

First NameLast Name
Therapist's Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Does {membersName} have a Start or SOS Coordinator? (TN)
Start Coordinator's Name:

First NameLast Name
Start Coordinator's Phone:
Please enter a valid phone number.Format: (000) 000-0000.
SOS Coordinator's Name:

First NameLast Name
SOS Coordinator's Phone:
Please enter a valid phone number.Format: (000) 000-0000.

If available, please upload:
PCSP, ISP, or current treatment plan

Cancelof
Previous Psychological or Psychiatric Evaluation/BSP

Cancelof
Should be Empty: