Referral Form

"*" indicates required fields

CLIENT INFORMATION

First Name*

Last Name*

Gender*

Male

Female

Date of Birth*

Phone*

Phone Type*

Home

Cell

Work

Language*

English

Spanish

Creole

Other

Insurance*

Diagnosis*

REFERRING AGENCY / PROVIDER INFORMATION

Court Ordered*

Yes

No

Agency Name*

Primary Contact*

First Last

Email

Phone*

Fax*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reason for Referral*

INITIAL SERVICE(S) REFERRING FOR (Please check all that apply)

Clinical Assessment

This initial appointment with a non-prescribing clinician initiates the therapeutic process. A diagnosis is identified and appropriate treatment recommendations are made including referral and linking to services within or outside of David Lawrence Centers for Behavioral Health. The assessment lasts approximately two hours

Psychiatric Evaluation

This is the initial appointment with a prescribing psychiatrist or ARNP and the goal is to prescribe medications. In the majority of cases, a clinical assessment must first be completed prior to referring to the psychiatrist.

Urine Drug Screen

Would you like a copy of the client's medical records upon completion of service?*

Yes

No

Our Organization

Who We Are

Campus Locations

Mental health

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Recovery Programs

Wellness Institute

For Clients

Resources

Wellness Institute

News & Events

2027 DLC Sound Minds

Our Organization

Who We Are

Campus Locations

Mental health

Addictions Treated

Recovery Programs

Wellness Institute

For Clients

Resources

Wellness Institute

News & Events

2027 DLC Sound Minds

Referral Form

CLIENT INFORMATION

REFERRING AGENCY / PROVIDER INFORMATION

INITIAL SERVICE(S) REFERRING FOR (Please check all that apply)

Mental health

Addictions Treated

Recovery Programs

Our Organization