Lighthouse Child & Family Services Referral Form

Client Information Client Information

Name of Client

Preferred Name

Date of Birth

Sex SexFemaleMaleIntersexPrefer not to specify

Gender GenderFemaleMaleTwo spiritNon-binaryTransgenderPrefer not to specify

Race

Client phone

Client email

Address

Address is Address isOwn homeBiological family homeAdoptive family homeFoster homeRelative careSafer at homeShelterFamily Services BuildingGroup homeResidential/HospitalOther

Client Lives With

Insurance Company

Date Insurance Began

Primary Client Policy ID#

Group #

Policy Holder Name

Policy Holder Date of Birth

Policy Holder ID#

Group #

Custodial Information Custodial Information

Primary Caregiver Name

Relationship

Date of Birth

Address

Phone #

Email Address

Legal Custody Legal Custody100%75%50%25%0%

Physical Custody Physical Custody100%75%50%25%0%

Additional Caregiver Name

Relationship

Date of Birth

Address

Phone #

Email Address

Legal Custody Legal Custody100%75%50%25%0%

Physical Custody Physical Custody100%75%50%25%0%

Other Relevant Custody Information (please specify if above caregiver are not biological parents)

Referral Source Referral Source

Referral Source Name & Phone

Today's Date

Referring Agency

Reason for Referral

Program/Service Program/Service Diagnostic Assessment (DA) Individual Therapy Family Therapy Couples/Marriage Therapy CSP/CSP Group ARMHS/ARMHS Group Adult DBT Program School-Linked Behavioral Health Day Treatment - Children's Program Day Treatment - Preschool Program

School/Grade/Teacher

Current and/or past services provided

Current Provider

DISCLAIMER DISCLAIMER I understand that this referral will not be processed without the proper accompanying documentation that may include, but is not limited to, necessary release(s) of information (ROI) forms and guardianship/custody documentation. Submit documentation via:

EMAIL: EMAIL: [email protected]

FAX: FAX: 651-342-8029 (Attn: Intake)

UPLOAD: UPLOAD: lighthousecfs.com > Forms > Upload Form