Love In Action Referral Information

Referral Information
Date of referral

MonthDayYear
Date
Referring Counselor
Referring Agency
Referring Counselor Phone
Format: (000) 000-0000.
Referring Counselor Email
example@example.com
YesNo
Client Name
DOB
SS
YesNo
If no please give name of legal guardian
Client / Legal Guardian Address
City
State
Zip Code
Phone
Format: (000) 000-0000.
Primary insurance
Secondary insurance
YesNo
If SO please attach a brief explanation
AnxietyAttention problemsHigh risk activitiesGets angry easilyImpulsivityMood swingsSubstance useSuicidal thoughtsTantrums/RagesSchool work problemsRelationship concernsHopelessness
Outpatient therapySober Living ServicesSUD Case ManagementDiagnostic AssessmentCPSTSubstance Abuse ServicesMental Health TreatmentTherapeutic Behavior Services
Known Diagnosis:
Medical Problems:
Medications
determination as to the most appropriate services for each consumer will be made based on this information; herefore, it is important to know as much as possible about each applicant. We ask that you provide the above information. in it's entirety before we start working with the client, so that we can make an accurate assessment of services needed.

Please forward all information to:

1585 COMPTON RD. MT. HEALTHY, OH 45231 Phone: 51-3-541-0405 Fax: 513-541-0413 www.weloveinaction.org
Should be Empty: