• Provider Referral Form

    Please contact us with any questions at 541-485-6340

  • REFERRAL ELIGIBILITY


    *READ FIRST*

    Due to HIPAA regulations, we are unable to accept referrals from providers under either of the following scenarios:

    • The provider does not fall under the Continuity of Care rule or
    • The referring provider cannot verify the individual has consented to the referral. 

    If your organization does not align with one of the following types listed below or the individual has not consented to the referral, do not continue with this form. Instead, please assist the individual in completing our Self-Referral Form.

    If you consider the referral to be needed urgently, please do not use this form.  Instead, contact us directly. 

  • Type of Referring Organization for Continuity of Care*

  • CONSENT FOR FOLLOW-UP WITH INDIVIDUAL  

    To ensure privacy, Laurel Hill Center requires verification of an individual's consent to be contacted prior to outreach. 

    If you are unsure if the individual gives consent for Laurel Hill Center to identify, select Save, confirm with the individual and then return to complete your form.   

    Please Note: Without consent to LHC identification, follow-up on the referral may be delayed.

  • Consent for LHC's identification through email*
  • Consent for LHC's identification through voicemail*

  • REFERRER INFORMATION

  • Date of Referral
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred Method of Follow-up

  • CLIENT INFORMATION

  • Legal Gender*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • What are the best days of the week for our staff to contact the individual?*
  • What are the best times of the day to contact the individual?*
  • Does the individual have insurance?*
  • Check all insurance types that apply:
  • Reason for Referral (check all that apply)*
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  • PARTICIPANT DEMOGRAPHICS FORM

  • Date of Birth
     - -
  • Current Legal Gender
  • Gender Identity
  • Racial Identity
  • Ethnicity
  • Where do you currently live?
  • Residential History: In the past three years, you have (mark all that apply):
  • Current Marital Status
  • Employment Status
  • Military Status
  • What is the largest source of your household income?
  • Primary Language
  • Do you need an interpreter?
  • Should be Empty: