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Quick Referral Form
Thank You for inquiring about our services.
You can reach us immediately for any urgent questions at 1-855-732-9585 or email
office@rebylt.org
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Client Name
*
First and last name
Your answer
Client Email
Your answer
Client Mobile Phone Number
*
Your answer
Client Date of Birth
MM
/
DD
/
YYYY
Client Last Four of SSn
Your answer
Child's Name 1
First and last name
Your answer
Child's Name 2
First and last name
Your answer
Child's Name 3
First and last name
Your answer
Child's Name 4
First and last name
Your answer
Medicaid/Insurance Provider
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Services Requested (Check All That Apply)
Initial Assessment
Psychotherapy
Behavioral Health Services
Other:
Other Notes/Comments
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REFERRAL SOURCE Name (Person/Entity)
*
First and last name
Your answer
REFERRAL SOURCE Email
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REFERRAL SOURCE Phone Number
Your answer
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