Client Referral Form

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Email *

Name: *

Date: *

YYYY

Date of Birth:

YYYY

Address:

Referring Party (who referred this client to therapy?): *

If self-referral please note below.

Client's Insurance:

Insurance Member ID number:

Please describe what has led to the client being referred to therapy: *

Please check all symptoms or impairments that may apply to this client:

depressed mood

hopelessness

Increased agitation and/or irritability

racing thoughts

Being easily startled

increased physiological arousal, tension, anxiety

excessive worry and feeling on edge

difficulty concentrating

Problems with family members, friends, school staff, or employers

Loss of pleasure in things once enjoyed

physical symptoms i.e. aches, pain, or past injuries

feeling insecure or unstable in his/her identity

Difficulty sleeping or poor quality of sleep

adjustment to a new stressor

phase of life issues

exposure or risk of exposure to abuse, neglect, or abandonment

a history of violence towards self or others

suicidal thoughts, gestures, or behaviors i.e. suicide threats, attempts, past hospitalizations

supportive people that can potentially support client in recovery process

desire to change

I, (Client's Name), do consent and agree to the authorization to release and exchange my information with Ashley Delgado M.S., LMFT 122489 to assist in the referral and intake process.

Please have the client sign and date below giving written consent that the clinician may contact them regarding this referral.

Name of the client who is releasing information to send and receive with Ashley Delgado, M.S., LMFT 122489:

Date of the release of authorization: *

YYYY

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