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LIGHTHOUSE BEHAVIORAL HEALTH AND WELLNESS CENTER

Referral Form

Referral Form

Date of Referral:

Time of Referral:

Client #:

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In Home Therapy

Therapeutic Mentor

Family Therapy

Family Stabilization Services

School Based Therapy

Trauma Center

Outpatient Therapy

Couples Therapy

Couples Therapy

(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:

Check Box

In-Person Services

Telehealth Services

Hybrid Services

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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In-Home Therapy

Marriage & Family Counseling

Mental Health Outreach

Perinatal Mental Health

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Therapeutic Mentoring

Trauma-Focused Therapy

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