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.
Given the sensitive nature of mental health, did you obtain client/patient consent to share their information with the Stronger Together Initiative?
*
Yes
No
Client Name:
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this client a resident of Cook County? If no, please note that this individual will not qualify for mental health services under the Stronger Together initiative.
Yes
No
Not Sure
Is this client an employee of The Chicago Lighthouse?
Yes
No
Not Sure
Date of Birth
-
Month
-
Day
Year
Date
Please check if the client is (Select All):
Visually Impaired
Blind
Hearing Impaired
Caretaker of Someone With a Disability
Veteran
Disabled
Unknown
Special Considerations (additional disabilities, languages spoken, social/living/transportation insecurities, etc)
Referring Professional Information
Your Name:
*
Your Organization/Group/Center
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about The Chicago Lighthouse Stronger Together Initiative?
*
Submit
Should be Empty: