LEO Clinic Community Referral Form

LEO Clinic Community Referral Form

Please complete this outpatient referral form. Complete all applicable fields; fields marked required must be filled in.
Referral Source
Name of Person Making Referral

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Sex/Gender
Patient Insurance Name
Patient Insurance Number
Last 4 of SSN
Patient's Current Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Patient's Primary Language
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent's Primary Language
Reason for Referral
Reason for Referral
Urgency / Priority
Diagnosis
Primary Diagnosis
ICD-10 Code
Additional Diagnosis Notes (Current medications, substance history, previous treatment provider, etc.)
Last Hospitalization and Reason for Hospitalization, if any
Requested Services
Reason for Referral (check all that apply)

Other
Consultation or treatment type

Other
Supporting details or notes
School and Educational Plan
School Name
Current Grade
Educational Plan
Consent and Signatures
Is Individual and Parent/Guardian aware of this referral?
Provider Acknowledgment
Signature
Signature Date

MonthDayYear
Date
Should be Empty:

Parent/Guardian Information