Flip the Switch Counseling LLC Referral Form

Flip the Switch Counseling LLC Referral Form

Standard online referral form based on the PDF referral document. Please complete the referral source, client information, insurance/consent, scheduling, clinical need, safety, supporting documents, and authorization details.
Referral Source
Date of Referral

MonthDayYear
Date
Referral Organization
Referral Contact Name

First NameMiddle NameLast Name
Title
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Fax
Best Time to Contact
Referral Type

Other
Referral Type - Other
Preferred Method of Communication

Other
Client Information
Client Full Name

First NameMiddle NameLast Name
Client Preferred Name
Client Date of Birth

MonthDayYear
Date
Client Age
Client Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Client City
Client State
Client Zip
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client Email
example@example.com
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Gender / Identity

Other
Gender - Self-describe
Pronouns
Primary Language

Other
Primary Language - Other
Interpreter Needed?
Parent / Guardian Name if Minor
Guardian Relationship
Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Guardian Email
example@example.com
Legal Custody / Decision-Maker if Known
Preferred Contact for Scheduling
Insurance & Consent
Primary Insurance
Primary Insurance Member ID
Secondary Insurance
Secondary Insurance Member ID
Insurance Subscriber if Different
Subscriber DOB

MonthDayYear
Date
PCP Name if Known
PCP Phone / Practice
Consent / Authorization Status

Other
Requested Services
Requested Services

Other
Requested Services - Other
Reason for Referral
Primary Concern
Presenting Symptoms / Functional Impact
Current Mental Health Diagnosis if Known
Current Medications
Current Behavioral Health Providers
Prior Counseling Location if Any
Has the individual previously received counseling?
Safety & Risk Screening
Current Safety Concern
Safety Concern Explanation / Immediate Actions Taken
Current Suicide Risk
Current Violence Risk
Current Substance Use Concern
Substance Use - Other
Additional Risk / Medical Factors

Other
Current Needs & Barriers
Current Needs / Barriers

Other
Current Needs / Barriers - Other
Special Accommodations Requested / Accessibility Needs
Goals for Services
Why are services being requested?
Desired Outcomes
Urgency

Other
Deadline Date if Any

MonthDayYear
Date
Reason for Deadline
Supporting Documents
Supporting Documents Attached

Other
Supporting Documents - Other
Authorization/Signature
Referral Source Signature
Signature Date

MonthDayYear
Date
Referral Source Printed Name
Referral Source Relationship / Role
Date Received

MonthDayYear
Date
Hour MinutesAM/PM Option
Reviewed By
Assigned Provider
Should be Empty: