Client Referral Form
If the client is in an emergency situation, please call 911 or call Crisis Connection.
Email address *
Date of referral *
MM
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DD
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YYYY
Is the Client aware that this referral is being made to Theraplace? *
Referral Source: Name of person referring *
Referral Source: Relationship to Client *
Referral Source: Agency/Clinic/Hospital Affilitation of person referring *
Referral Source: Phone number *
Referral Source: Fax number (optional)
Referral Source: E-mail (optional)
Referral Source: Referring client for which service? *
Required
Client Information: Name *
Client Information: Date of Birth *
MM
/
DD
/
YYYY
Client Information: Address *
Client Information: Phone Number *
Client Information: E-mail
Parent/Guardian Information (if applicable): Name
Parent/Guardian Information (if applicable): Address
Parent/Guardian Information (if applicable): Phone Number
Parent/Guardian Information (if applicable): E-mail
Payment: Choose one *
Insurance (if applicable): Insurance Carrier
Insurance (if applicable): Policyholder
Insurance (if applicable): ID Number
Insurance (if applicable): Group Number
Current Services Being Utilized by Client *
Required
Currently Prescribed Psychiatric Medication (if applicable)
Currently Family Situation *
Presenting Issue/Symptoms/Needs *
Goals/Specific Outcomes Expected *
Other Information
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