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Referral Form

If you or someone you know is experiencing emotional, psychological, or behavioral challenges, psychotherapy can be an effective and supportive pathway toward healing and growth. Whether you're navigating life transitions, coping with stress or trauma, or seeking tools to manage mental health conditions like anxiety or depression, psychotherapy offers a safe space to explore your concerns and develop strategies to thrive.

Referring someone to therapy can be a meaningful step in their journey toward improved well-being. With the guidance of a trained therapist, clients can gain self-awareness, build resilience, and achieve their personal goals. Let's work together to foster mental health and empower positive change. Please submit the form below to refer a client.

Steps to get connected:

1. Complete the LTS Client Referral Form: Complete the form to the best of your ability.

2. Connect with appropriate services: An LTS team member will review the form and match you with the most appropriate services.

3. Schedule initial appointment: An LTS team member will contact you to schedule your initial appointment based on availability.

 

The following information will aid in understanding the client's needs and ensuring they are matched with appropriate services.

Referral Form

Today's Date
Are you completing this form for yourself or another person?
I am completing this for myself
I am completing this form for another person
Birthday
Which housing type best describes your living situation?
Homeless
Housing Program (Independent Living)
Living with Others
Living with Family
Living Alone
Preferred Method of Service
Preferred contact method (By submitting this contact form you consent to being contacted, which includes our company information.)
Sex (Please note we ask for insurance purposes)
Gender Identity
Pronouns (Select all that apply)
Race/Ethnicity (Select all that apply)
Check all services you are interested in receiving:

Insurance

Will services be paid out of pocket OR through insurance?
I'm paying out of pocket
I'm using insurance
Will you be using Services through EAP?
Yes
No

If using EAP, please provide the formal letter showing the authorization code, number of sessions authorized, and effective dates.


Please indicate who is the primary policy holder.
Client
Spouse
Parent/Guardian
Who is the insurance provider?
Primary policy holder's date of birth
Primary policy holder's sex as indicated on their insurance

Services

Preferred frequency of sessions
How did you hear about us?
Are you a former client of Lighthouse Therapeutic Services?
Yes
No

Resources

Would you like support with any of the following:

Thank you for taking the time to complete our referral form.

We will be in contact with you soon. 


Entrer en contact

Adresse

5557, avenue Baltimore

Bureau 500-1535

Hyattsville, MD 20781

Heures

Du lundi au vendredi : de 9h00 à 20h00 HNE

Samedi : 9 h 00 - 15 h 00 HNE

Dimanche : Fermé

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Lighthouse Therapeutic Services SMS Consent and Privacy Policy:
By providing your phone number you consent to receiving SMS messages from

Lighthouse Therapeutic Services solely concerning your LTS account. Frequency may vary.

Message & data rates may apply. Reply STOP to opt out of further messaging.

View terms and privacy policy here.  Mobile information will not be shared, sold, or conveyed

to third parties for marketing/promotional purposes.

Merci d'avoir soumis !

© 2022 par Lighthouse Therapeutic Services, LLC. Conçu par Dessins Artsyrella

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