Stronger Together Mental Health Support External Referral Form Logo
  • Stronger Together Mental Health Support External Referral Form

    Learn More about Stronger Together: https://chicagolighthouse.org/stronger-together/
  • Client Information

    This referral form is secure and HIPAA compliant under our business Associate Agreement (BAA) with JotForm. Please share as much information about the client or patient you are referring to us for mental health support at The Chicago Lighthouse.
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  • Referring Professional Information

  • Should be Empty: