320-983-2335

Lighthouse Child & Family Services Referral Form

    Client Information
    Address:
    Address is:
    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
    Address:
    Phone #:
    Email Address:
    Legal Custody:
    Physical Custody:
    Address:
    Phone #:
    Email Address:
    Legal Custody:
    Physical Custody:
    Other Relevant Custody Information (please specify if above caregiver are not biological parents):
    Referral Source
    Referral Source Name & Phone:
    Today's Date:
    Referring Agency:
    Reason for Referral:
    Program/Service
    Current services and/or past services provided:
    Current Provider: