414-800-9757
info@lifelinkll.com

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Counseling and Therapy Referral Program

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Counseling and Therapy Referral Program

Personal Information

First Name *

Last Name

Date of Birth *

Year

Month

Day

Phone Number *

Email Address (if applicable)

Street Address *

City

State

Zip Code

Insurance ID

Reason for Referral

Issues Addressed (Check all that apply) *AnxietyAttachment DisordersBehavior IssuesDepressionDivorceFamily ConflictGriefInfidelityLGBT ConcernsParentingRelational IssuesSelf-EsteemStressOther

Specify

How long have you been experiencing this concern?

What are you hoping to achieve through counseling?

Preferences

Preferred Counseling Format *In-PersonTelehealth/VirtualNo Preference

Do you need accommodations? *Language AssistanceMobility AssistanceOther

Specify

Additional Notes (Optional)

Consent and Authorization *

I consent to the use of my information to coordinate counseling and therapy services.

Upload Supporting Documents (Optional)

Drag and Drop (or) Choose Files

You may upload any documents, such as treatment plans, medical notes, or other relevant files:

Personal Information

Name

Today's Date

Brithdate

Race/Ethnicity

American Indian or Alaskan Native Black or African American Native Hawaiian or Pacific Islander Hispanic or Latino White

Address

City/State/Zip Code

Telephone Numbers

Home

Cell

Work

Other Phone

More Informations

Do you have a disability?

Yes No

Are you applying for a bus pass

Yes No

Purpose for bus pass?

Please check all items you use when traveling?

Cane White Cane Walker Crutches Manual Wheelchair Power Wheelchair Power Scooter Oxygen Tank Service Animal Other None

Do you travel with a personal care attendant?

Yes No Sometimes

Transportation Type

If you use a wheelchair or scooter, are you able to transfer into a car seat?

Yes No

If you use a wheelchair or scooter, are you able to transfer into a Minivan?

Yes No

If you use a wheelchair or scooter, is it wider than 30 inches?

Yes No

If you use a wheelchair or scooter, is it longer than 48 inches?

Yes No

If you use a wheelchair or scooter, is it more than 600 pounds when occupied?

Yes No

Medical

Do you receive Medicare?

Yes No

Do you receive Medical Assistance/Medicaid/MA (Forward Card)?

Yes No

LifeLink, Inc. – Where Care Meets Connection.

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606 W Wisconsin Ave, Ste 202, Milwaukee, WI 53203
info@lifelinkll.com
414-800-9757
414-710-2556

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