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LIGHTHOUSE BEHAVIORAL HEALTH AND WELLNESS CENTER

Project Aspiration Referral Form

Project Aspiration Referral Form

Date of Referral:

Time of Referral:

Client #:

Check Box

Intake Assessment

Offender Intervention

Domestic Violence Counseling

Safety Assessment

Advocacy Case

Community Education Service

(Office Use Only) Assigned To:

Date Assigned:

Intake Date:

Date of First Contact:

Client/Family Name:

DOB:

Gender:

Name of Caretaker:

Relationship to Client/Family:

Emergency Contact:

Emergency Contact Phone No:

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

Counselor Preferences:

Female

Male

Either

Email Address:

Email Address:

Address:

Preferred Phone No:

Back up/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?

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