LLBH REFERRAL FORM

LEADING LIGHT BEHAVIORAL HEALTH INC

Client Referral Form
Today's Date *

Month Day Year
Date Hour Minutes AM/PM Option
Referral Source
Service Type *

Adolescent Group Individual Counseling Family Counseling Psychoeducation Group DBT Skills Group NP/Medication Management Couples Counseling
Reason for Referral *
Give as much detail as possible.
Client Name *

First Name Last Name Pro nouns
Client Phone Number *

Area Code Phone Number
Client Email *
example@example.com
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State

Zip Code
Type a question

Male Female N/A
Race
Policy Holders Name and DOB *
Insurance Number *
Insurance Type *
Diagnosis
History *

History of Trauma History of Auditory Hallucinations History of Suicidal Thoughts History of Violence History of Suicide attempts History of Visual Hallucinations None
Please explain all the boxes you checked above. *
Type N/A if it does not apply.
History of hospitalizations? *
Please provide locations, dates, reason for hospitalization and treatment provided.
History of Substnce Use *
Provide details of history of substance use. Please provide current and past use. What substance used, frequency, intensity, and duration usage.
Current or Past Prescriber or relevant provider
Please provide name, phone number and address for the provider.
Medication and Allergies *
Please provide name of medications, dosage, and reason.
Additional comments
Signature *

Clear
Files: Please attach a copy of your insurance card. Front and back.

Browse Files
Along with a release and any additional necessary documents. Cancel of
Should be Empty:

LEADING LIGHT BEHAVIORAL HEALTH INC