LakeView Neighborhood Alliance

LakeView Neighborhood Alliance

Referral Form for Healing Pathways

Information about Person Completing Referral
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.

Individual Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Individual aware of this Referral?

YesNo
Payment Method

LNA Community Grant RecipientSelf-PayPrivate InsuranceMedicaidMedicare
Insurance Policy Number
Insurance Policy Holder Name
Who hold the insurance policy

SelfSpouse/PartnerParentOther
Type of Services Needed

AdultChildAdolescentYouth to Young TransitionElderly
Program Needed

Individual TherapyGroup TherapyComprehensive Clinical AssessmentWomen Support GroupMen Support GroupTherapeutic Youth Advocate (Mentor)Peer Support ServicesCase Management ServicesTherapeutic Book Club
School Name
Parent/Guardian Name

First NameLast NameRelationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Specify service Individual is considering (Adult)

Case Management (CM)Family Therapy (Mental Health ONLY)Group Therapy (Mental Health ONLY)Individual Therapy (Mental Health ONLY)Intensive Case Management (ICM)Peer SupportsSupported Employment (Mental Health ONLY)**Substance Use services
Individual Gender

MaleFemaleOther
Individual Primary Language

EnglishSpanishOther
Reason for Referral
Current Medications
Select all applicable challenges below for the Individual referred (check all that apply)

Ability to avoid dangers/hazardsAngerAnxietyCommunity Linkage of ServicesDaily living skillsDepressionGriefHousingHygieneImpulsive BehaviorsJuvenile Justice/Court InvolvedLife SkillsMaintaining personal affairsMedication EducationNutritionalPhobia/sPRTF/Hospital DischargeSafe living situationSchool behaviorSelf-Advocacy SkillsSelf HarmSeparation IssuesSocial SkillsSubstance UseSustainable employmentTraumaTruancyWhole Health/WellnessYouth to Young Adult TransitionOther
Should be Empty: