Clinician Referral Form | Improving Lives Counseling Services

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Referrer's Information
Clinician's Name*
First Last
Clinician's Phone Number*
Clinician's Email Address*
Potential Client Information
Potential Client's Name*
First Name Last Name
Potential Client's DOB (preferred) or Approximate Age Below
Month
Day
Year
Approximate Age*
Please enter a number from 1 to 120.
Parent / Legal Guardian (if applicable)
Second Legal Guardian (if applicable)
Primary Phone*
Secondary Phone
Additional Phone
Email
Location (City/Town)*
Problem(s) / Behavior(s) / Situation(s)
Significant History
Insurance Provider*
ID #*
School Information (if applicable)
Grade
Please enter a number from 0 to 12.
Teacher(s)
Is student on an IEP?
Other Information
Staff Member Preference Name*
Case #
Upload Documents
Max. file size: 50 MB.
Email
This field is for validation purposes and should be left unchanged.

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