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LIGHTHOUSE BEHAVIORAL HEALTH AND WELLNESS CENTER

Group Referral Form

lighthouse

Group Referral Form

Date of Referral:

Time of Referral:

Client #:

Please indicate which support group this referral is for:

Perinatal Mental Health

Youth Grief

COVID Peer Support

Teen Pregnancy

Parents of Addicted Youth

Parenting

Mindfulness / Mediation

Adult Domestic Offender

Divorce

Life Over Matter / Life Workhop

Domestic Violence Offender

Adult Grief

Anxiety Management

Depression Support

Grief & Loss Support

Substance Abuse Recovery

Trauma Recovery

Self Esteem & Confidence Building

Healthy Relationships

Cognitive Behavioral Therapy(CBT)

Dialetical Behavior Therapy(DBT)

Parenting Skills Workshop

Mental Health Education

Mindfulness and Meditation

Coping Skills Workshop

Art Therapy

Stress Management

Recreational Activities

Veterans Support

Music Therapy

Teen Support

Chronic Illnss Support

(Office Use Only) Assigned To:

Date Assigned:

Intake Date:

Date of First Contact:

Client/Family Name:

DOB:

Gender:

Name of Caretaker:

Relationship to Client:

Emergency Contact:

Emergency Contact #:

If client is a minor, who has legal and physical custody:

Counselor Preferences:

Email Address:

Address:

Preferred Phone #:

Alternative Phone #:

Primary Language:

Interpreter?

Yes

No

Scheduling needs:

Nationality (Country of Origin):

Race:

School:

Health Center/PCP:

Referral Source Name:

Role with Family/Agency:

Phone:

Fax No:

Email Address:

Insurance Information:

Primary Insurance Plan:

Secondary Insurance Plan:

Auth Approval #:

Date Authorization Submitted:

Date Authorization Approved:

Auth Start Date:

Auth End Date:

Units Approved:

Axis 1 (Current Diagnosis Dx Code(s):

Who generated diagnosis and when?

What are the current concerns or behaviors for the individual/family member (Patient) that led to the referral?

What has been helpful for the individual/family (Patient) currently or in the past? What are their strengths?

Submit Referral

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