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 Caregiver 1 Relationship Date of Birth Address Phone # Email Address Legal Custody Legal Custody100%75%50%25%0% Physical Custody Physical Custody100%75%50%25%0% Caregiver 2 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 Individual therapy Family therapy Couple/Marriage therapy CSP/CSP Group ARMHS/ARMHS Group Adult DBT Program Adolescent DBT Program School Linked Mental Health Intensive Treatment in Foster Care Children Day Treatment Preschool Day Treatment School/Grade/Teacher Current services and/or past services provided Current Provider Disclaimer Disclaimer I understand that this referral will not be processed without the proper accompanying documentation (Release(s) of Information, Guardianship/Custody documentation, etc.) if applicable. Submit documentation via email (shelley@lighthouse.health) or fax (651-342-8029, Attn: Intake) to avoid delays in processing. Submit
