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Provider Referral Form
SouthLight Healthcare enhances the quality of life for adults, youth, and families impacted by substance abuse and mental health disorders through integrated care, prevention, education, and advocacy.
Today's Date:
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Name of the person submitting referral:
Your answer
What is your Phone number? :
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What is your Email Address? :
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Referring Agency (if applicable):
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Service Requested (if known): (Please click all that Apply)
Required
Client Information
Client First Name
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Client Last Name
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Client Maiden Name (female only)
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Client Date of Birth:
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Client Address:
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City
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State
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County
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Zip Code
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Client Primary Phone Number
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Is it okay to leave a voicemail?
Client Secondary Phone Number:
Your answer
What is the best time to reach Client or Legal Guardian? (if known):
Time
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What is the primary language spoken in the client's home?
Client Gender:
Client Race
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Client Marital Status:
Client Tobacco Usage:
Client Employment Status:
Highest Grade Level Completed by Client:
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Client Annual Household Income?
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What is the number of individuals in your client's household?
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What is the number of individuals under 18 in your client's household?
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Client Insurance Policy Subscriber:
Payer Name:
Client Insurance Company Name:
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Client Policy/ID Number:
Your answer
Client Benefits Phone Number (as it appears on card):
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Name of Legal Guardian to client (if applicable):
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Current client medications and dosages (if known):
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Current mental health/substance use (if known):
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Has client been at a hospital, emergency room, crisis center, or utilized mobile crisis for mental health symptoms in the past year?
Any previous mental health and/or substance abuse treatment?
What is your Relationship to the Client? :
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Is the client aware that you are making this referral?
Do we have a release to speak with you?
Briefly describe why you are referring:
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Any other comments or information?
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