Phone Screening Form

NEW REFERRAL FORM
Client Demographics:
Date of Referral
MonthDayYear
1
Referral Source
Is client a minor?
YesNo
Client Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Mailing Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Email
example@example.com
Client’s Caregiver Information
Caregiver Name
First NameLast Name
Relationship to Client
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Insurance Information
Insurance Carrier #1
ID#
Comments
Name of Insured
First NameLast Name
DOB of Insured
MonthDayYear
Date
Behavioral Health Phone#:
Please enter a valid phone number.
Secondary Insurance Carrier #2
ID#
Comments
Name of Insured
First NameLast Name
DOB of Insured
MonthDayYear
Date
Behavioral Health Phone#:
Please enter a valid phone number.
Presenting Problem
History Trauma
History of Counseling
Areas Affected
HomeWorkSchoolSocialLegal
Safety Concerns
NoneSuicidalHomicidalSelf-HarmingDomestic ViolenceOther
Does the client have a homicidal or suicidal plan in place?
YesNo
Safety Action Taken

Behaviors
HallucinationsDelusionsManiaAlcohol/Substance Use
Client Preferences
OnlineFemale ClinicianMale ClinicianNo Preference
Client Availability
Days
Hours
Comments
Therapist Assigned and Date Assigned
Name
First NameLast Name
Date
MonthDayYear
Date
Name/Signature of Person Completing Referral
Clear
**Please inform the clinician of the referral form. If the clinician agrees to the referral. Create Clients in Simple Practice and Provide Biller with insurance information. Referral form should be uploaded to client file**
Should be Empty:

NEW REFERRAL FORM