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Referral Form

Today's Date
Day
Month
Year
Are you completing this form for yourself or another person?
I am completing this for myself
I am completing this form for another person
Birthday
Day
Month
Year
Which housing type best describes your living situation?
Homeless
Housing Program (Independent Living)
Living with Others
Living with Family
Living Alone
Multi-line address
Preferred Method of Service
Preferred contact method (By submitting this contact form you consent to being contacted, which includes our company information.)
Sex (Please note we ask for insurance purposes)
Gender Identity
Pronouns (Select all that apply)
Race/Ethnicity (Select all that apply)
Check all services you are interested in receiving:

Insurance

Will services be paid out of pocket OR through insurance?
I'm paying out of pocket
I'm using insurance
Will you be using Services through EAP?
Yes
No

If using EAP, please provide the formal letter showing the authorization code, number of sessions authorized, and effective dates.


Please indicate who is the primary policy holder.
Client
Spouse
Parent/Guardian
Who is the insurance provider?
Primary policy holder's date of birth
Day
Month
Year
Primary policy holder's sex as indicated on their insurance

Services

Preferred frequency of sessions
How did you hear about us?
Are you a former client of Lighthouse Therapeutic Services?
Yes
No

Resources

Would you like support with any of the following:

Thank you for taking the time to complete our referral form.

We will be in contact with you soon. 


Sarah Brown

David Johnson

Family counseling needed

ተገናኝ

አድራሻ

5557 ባልቲሞር አቬኑ

ስዊት 500-1535

ሃያትስቪል፣ ኤምዲ 20781

ኢሜይል፡- info@ltherapeuticservices.com

ስልክ፡ 301-781-7885

ሰዓታት

ከሰኞ - አርብ: 9:00AM - 8:00PM EST

ቅዳሜ: 9:00AM - 3:00PM EST

እሁድ፡ ተዘግቷል።

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Lighthouse Therapeutic Services SMS Consent and Privacy Policy:
By providing your phone number you consent to receiving SMS messages from Lighthouse Therapeutic Services solely concerning your LTS account. Frequency may vary.

Message & data rates may apply. Reply STOP to opt out of further messaging. View terms and privacy policy here.  Mobile information will not be shared, sold, or conveyed to third parties for marketing/promotional purposes.

ስላስገቡ እናመሰግናለን!

© 2022 በ Lighthouse Therapeutic Services፣ LLC። በ  የተነደፈArtsyrella ንድፎች

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