LEADING LIGHT BEHAVIORAL HEALTH INC
Client Referral Form
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Minutes
AM
PM
AM/PM Option
Referral Information
Referral Source
Reason for Referral
*
Give as much detail as possible.
Service Type
*
Individual Counseling
Family Counseling
Couples Counseling
Child/Adolescent Therapy
NP/Medication Management
Group Selection
Adolescent Group
Art Therapy Group
General DBT Group
BIPOC DBT Group
Trauma Group
Couples Group
Adolescent Group
Psychoeducation Group
For Group therapy
Preferred top 2 Providers
Guan Ellerbe
Nielle Milinazzo
Koralys Ozuna
Kyler Thai
Edwing Guilloteau
Elliette Utset
Janine Groman
Gregorit Sanchez
Kerri McKinnon
Michelle Tokar
Samantha Harrington
Shantel Carrasco
Shaquiri Manns
Jasmin McElroy
Natisha Moore
Madyna Rancifer
Devorah Kosowsky
Practice Providers
Referral Concern
*
Anxiety
Depression
Grief
Mood disorder
Personality Disorder
Trauma
Post/Pre Incarceration
Perinatal
Gender Dysphoria
Client Details
Client Name
*
First Name
Middle Name
Last Name
Client Phone Number
*
Please enter a valid phone number.
Client Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Is the client a minor (under 18)
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Gender Identity
*
Male
Female
N/A
Pronouns
*
Race
*
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Ethnicity
*
Hispanic
White alone, non-Hispanic
Black or African American alone, non-Hispanic
American Indian and Alaska Native alone, non-Hispanic
Asian alone, non-Hispanic
Native Hawaiian and Other Pacific Islander alone, non-Hispanic
Some Other Race alone, non-Hispanic
Multiracial, non-Hispanic
Policy Holders Name and DOB
*
Insurance Number
*
Insurance Type
*
Aetna
Allways Health Partners
Beacon
Blue Cross Blue Sheild
BMC Healthnet
Cigna
Fallon Health
Harvard Pilgrim
Optum
Public Health Plans
Senior Whole Health
Tufts Public
Tufts Commercial
Unicare
United Health Care
Mass Health
MBHP (6 month wait)
Medicaid
Clients with MBHP are encouraged to switch to Beacon. We have a 6 month wait for MBHP clients.
Client History
Diagnosis (if any)
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 Substance 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.
List all Medication, use, and dose. Please let us know of all Allergies
*
Please provide name of medications, dosage, and reason.
Legal
18+ skip this section
Who is the legal guardian?
First Name
Last Name
Relationship to Child
Guardian 2
First Name
Last Name
Relationship to child
Is there a court order or restraining order in place? (Please upload a copy)
*
Yes
No
Is there a state agency involved?
Yes
No
If there is a state agency involved, please provide agency type, contact person, and contact information.
DCF, Court, DYS, DMH, etc.
Additional comments
Signature
*
Clear
Files: Please attach a copy of your insurance card. Front and back. Hospital records, discharge forms, medication list, etc.
Browse Files
Along with a release and any additional necessary documents.
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