Instilling Light Mental Health Therapy Referral Form
Thank you for helping connect people to care, Please fill out as much as you can to help us schedule the right type of support.
Referral Source Name
*
Name
Office Name
Referral Source Email
example@example.com
Referral Source Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Source Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Client Full Name
*
First Name
Last Name
Parent or guardian name (if minor)
First Name
Last Name
Client Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client's email
example@example.com
Clients Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Client State of residence
*
Type of Therapy Needed
Individual Therapy
Couple Therapy
Family Therapy
Child/Teen Therapy
Other
Brief description of presenting concern
Insurance
Aetna
Anthem/BCBS
Cigna/Evernorth
Intermountain EAP
Colorado Medicaid
United
Kaiser
Other/unknown
Known Scheduling Information or Preferences
Anything else you think is important or would like to add:
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I have obtained the client's permission to share this information with Instilling Light for the purpose of seeking therapy services
Yes
No
Submit Referral
Should be Empty: