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Lighthouse Therapeutic Services, LLC.

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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

First name*

Last name*

Birthday*

Day

Month

Year

Parent/Guardian Name

Parent/Guardian Contact Information

Which housing type best describes your living situation?*

Homeless

Housing Program (Independent Living)

Living with Others

Living with Family

Living Alone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Email*

Phone

Preferred Method of Service*

In-person

Virtual

Preferred contact method (By submitting this contact form you consent to being contacted, which includes our company information.)

Phone

Text

Email

Sex (Please note we ask for insurance purposes)*

Gender Identity*

Pronouns (Select all that apply)*

He/Him

She/Her

They/Them

Ze/Hir

Other, please specify

Race/Ethnicity (Select all that apply)*

American Indian/Alaska Native

Asian

Black or African American

Native Hawaiian/Other Pacific Islander

White

Hispanic/Latino

Biracial/Multiracial

Declined to answer

Unavailable/Unknown

Other, please specify

Check all services you are interested in receiving:*

Therapy

Medication Management

PRP

Substance Abuse Treatment & Counseling

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.

EAP Letter

Please indicate who is the primary policy holder. *

Client

Spouse

Parent/Guardian

Legal name (first/last) of primary policy holder.

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

Phone

Member ID Number

What is the home address associated with the primary policy holder’s insurance?

Services

How would you describe the presenting problem?*

What would be the focus during therapeutic sessions?

Describe your ideal Therapist. Is there a gender, ethnic, cultural, or modality preference?

Preferred frequency of sessions

Weekly

Every other week

Unsure

What are your availability days & time frames including weekends?

How did you hear about us?

If Other, Specify:

Are you a former client of Lighthouse Therapeutic Services?*

Yes

No

Government Identification (ID)

I do not have an ID at the moment

Health Insurance Card - Front

Health Insurance Card - Back

I do not have an insurance card at the moment

Medication List

Other Healthcare Paperwork (Hospital Discharge, Medical Records, etc.)

Resources

Would you like support with any of the following:

Job Training

Veterans Affairs & Claims Assistance

Court Ambassadors

Child Support Assistance

Food Assistance

Medical Insurance Assistance

Employment Assistance

GED/College Enrollment Assistance

Youth & Teen Services

Mental Health Services

Family Reunification Services

Transportation Assistance

Housing Assistance

Legal Assistance

ID Services

Birth Certifications Assistance

Re-entry Support Program

Case Management

Peer Support

Anger Management Courses

Workshops

Computer Fundamentals

Budgeting and Credit Repair

Please explain what other resources you can benefit from.

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

We will be in contact with you soon.

John Doe

Alice Smith

Seeking therapy for anxiety

Nweta kọntaktị

adreesị

5557 Baltimore Okporo ụzọ

Suite 500-1535

Hyattsville, MD 20781

Email: info@ltherapeuticservices.com

Ekwentị: 301-781-7885

Oge awa

Monday - Friday: 9:00AM - 8:00PM EST

Satọde: 9:00AM - 3:00PM EST

Sunday: Emechiela

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.

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