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Lever Mind Brief Referral Form for Mental Health Counseling form
* Indicates required question
Date of Referral
*
MM
/
DD
/
YYYY
Name (First, MI, Last)
*
Your answer
Gender
*
Male
Female
Other
If we are unable to reach you, who do we have permission to call to reach you?
Include name, relationship, and number Name
*
Your answer
Client's Date of Birth
*
MM
/
DD
/
YYYY
Client's email address/care taker
*
Your answer
Client's Address
*
Your answer
Contact Number(s)
*
Your answer
Name of Insurance
*
Amerihealth
Medstar
Amerigroup
Straight DC Medicaid
United Health (commercial plan)
Cigna
Aetna
Blue Cross Blue Shield (BCBS)
Other:
Required
Insurance Policy Number
*
Your answer
Clients availability (Sessions are Virtual)
*
Your answer
Monthly Check-In's (In place of weekly sessions)
Yes
No
Comments
Your answer
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