Updated LLBH REFERRAL FORM

LEADING LIGHT BEHAVIORAL HEALTH INC

Client Referral Form
Today's Date*

MonthDayYear
DateHourMinutesAM/PM Option
Referral Information
Referral Source
Reason for Referral*
Give as much detail as possible.
Service Type*

Individual CounselingFamily CounselingCouples CounselingChild/Adolescent TherapyNP/Medication Management
Group Selection
For Group therapy
Preferred top 2 Providers
Practice Providers
Referral Concern*

AnxietyDepressionGriefMood disorderPersonality DisorderTraumaPost/Pre IncarcerationPerinatalGender Dysphoria
Client Details
Client Name*

First NameMiddle NameLast Name
Client Phone Number*
Please enter a valid phone number.
Client Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Is the client a minor (under 18)*

YesNo
Address*

Street Address

Street Address Line 2

City

Zip Code
*

Street Address

Street Address Line 2

CityState

Zip Code
Gender Identity*

MaleFemaleN/A
Pronouns*
Race*
Ethnicity*
Policy Holders Name and DOB*
Insurance Number*
Insurance Type*
Clients with MBHP are encouraged to switch to Beacon. We have a 6 month wait for MBHP clients.
Client History
Diagnosis (if any)
History of Seizures?
History*

History of TraumaHistory of Auditory HallucinationsHistory of Suicidal ThoughtsHistory of ViolenceHistory of Suicide attemptsHistory of Visual HallucinationsNone
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.
Please do not skip for prescriber referrals. Please select all that have been completed and attached.

Release of InformationComprehensive AssessmentMedication List
Legal

18+ skip this section
Who is the legal guardian?

First NameLast NameRelationship to Child
Guardian 2

First NameLast NameRelationship to child
Is there a court order or restraining order in place? (Please upload a copy)*

YesNo
Is there a state agency involved?

YesNo
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. Cancelof
Should be Empty:

LEADING LIGHT BEHAVIORAL HEALTH INC

Referral Information

Client Details

Client History

Legal