NEW LIFE COUNSELING & WELLNESS CENTER, INC. Referral Screening Form

In ClaimTrak Assigned to: Date Assigned: Program:

Service/Model Requested: Dx (DSM 5 code):

Last Name (DCF: Family name and individual served – e.g. Johnson/Doe):

First Name (First name of individual served):

DOB (DOB of individual served): Sex: Address (Address of individual served) *In case, if it is a reunification, use the addresswhere the child is currently residing, unless this child will be going home within two weeks of service:

Street:

City, State, Zip: Telephone (Home and cell of individual served): Home: Cell:

Email:

Referral Source Name: Tel:

Reason for Referral:

Date Received (Date of Referral):

Completed By:

Marital Status:

Preferred/Requested Language:

Guardian (If any):

Guardian Address: Street:

City, State, Zip Code:

Cell: Guardian Telephone: Home:

Race:

Ethnicity:

Emergency Contact:

Name: Telephone:

Street: City, State, Zip:

Relationship to client:

Self-Pay? (If yes, skip Insurance section) Yes No Insurance Type Guarantor Member ID # Priority

Revised: 03/31/2016 NLCWC, Inc.

Guarantor Authorization Date Authorization # Quantity Thru: To:

To:To:

Thru: Thru:

Co-Pay: $

Smoker

Clinical Issues

Trauma If it’s a concern or reason for seeking services, describe below:

If it’s a concern or reason for seeking services, describe below:

Legal Issues If it’s a concern or reason for seeking services, describe below:

Medical Issues If it’s a concern or reason for seeking services, describe below:

Safety Concerns If it’s a concern or reason for seeking services, describe below:

Current medications: Other agencies involved: Special Requests:

Revised: 03/31/2016 NLCWC, Inc.