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 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 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.