New Leaf Clinic Referral Form
✅  Required Information: 
  • 🌿Client Name
  • 🌿Client Contact Information
  • 🌿Client Insurance (helpful but we can obtain this from the client) 
📞 New Clients call for a faster response!
  • 502-690-4286 
✅ Confirmation within 24 hours from receipt. 
🆘 If you are in crisis, please call 911 ☎️ 
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Client Name (First and Last) *
Client Date of Birth (if known) *
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Client Email *
Client Phone Number *
Client Insurance
Client SSN (for insurance verification purposes only)
Name of Referring Organization *
Name of the person sending the referral. *
Email of the person sending the referral.
Phone number of the referring person
What type of services does this client need?
Clear selection
Client Immediate Needs: Check all that apply
Please list Mental Health concerns or needs?
History of Substances Used
Last Day of Use
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Does this client actively use Alcohol or Benzodiazepines? *
Are there any concerns for safety - inability to care for self, suicidal thoughts, or homicidal thoughts.
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I agree to the terms & conditions. Yes, I want to receive updates and reminders via text message from New Leaf Clinic. By providing my phone number and submitting this form, I agree to receive recurring text messages. Message and data rates may apply. Reply STOP to unsubscribe. View terms
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