Phone Screening Form

NEW REFERRAL FORM
Client Demographics:
Date of Referral
MonthDayYear
1
Referral Source
Is client a minor?
Client Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Presenting Problem
2
History Trauma
3
History of Counseling
4
Areas Affected
Safety Concerns
Does the client have a homicidal or suicidal plan in place?
Safety Action Taken

Behaviors
Client Preferences
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:

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NEW REFERRAL FORM