Referral – Limitless Possibilities

Limitless Possibilities

Treatment Modalities

Full Name

Phone

Client Name

Legal Guardian’s Name (if applicable)

Phone Number

Client's Date of Birth

Client’s Address:

Referral Source Name

Referral Source Telephone Number

Social Security Number (to verify insurance coverage)

Insurance Name

Insurance Telephone Number

Insurance Number

Member ID Number

Are there other service providers involved (CSA, Psychiatrist, CBI)?

Yes No

If “Yes” is checked above, please provide the contact information:

Services Needed/Requested

Individual Therapy Family Therapy Intensive Mentoring/CBI Marital Therapy Other

Does Client attend School?

Yes No

If “Yes” is checked above, please provide the name of the school client attend

Presenting Problem or Area of Concern