Behavioral health referral form - Client Information
Please complete the referral and intake information. All fields are optional unless marked required in the original PDF.
Client Information
Client Type
Adult
Child/Adolescent
Gender
Address
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Parent/Guardian Name (If Minor)
Guardian Contact Information
Insurance Provider
Presenting Concerns
Mental Health Concerns
Anxiety
Depression
Trauma/PTSD
Mood Instability
Behavioral Issues
ADHD
Suicidal Ideation
Self Harm
Psychosis
Grief
Anger/Emotional Regulation
Other
Brief Description of Mental Health Concerns
Referral Information
Date of Referral
-
Month
-
Day
Year
Date
Referral Source
Facebook
Instagram
Word of Mouth
Eventbrite
Other
Referral Source Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Source Email
example@example.com
Reason for Referral
Mental Health Services
Substance Use Disorder (SUD) Services
Co-Occurring Treatment
CPST
TBS (Children Only)
Peer Support Services
Case Management
Medication Management
Psychiatric Evaluation
Crisis Intervention
Other
Mental Health Client Details
Client Name
Client DOB
-
Month
-
Day
Year
Date
Client Age
S S Number
Emergency Contact
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Card
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Other Mental Health Concern (specify)
Other Reason for Referral (specify)
Consent and Signature
*
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