Life Line Counselors
200 1st Ave W, Ste. 400
Seattle, WA. 98109
 (206)274-7861 Ext 701
Fax: (206)257-0584

Patient Referral Form for Mental Health Counseling
Clinician/Provider Form
__________________________________________________________________
Thank you for submitting your referral. Please complete this form and submit to Clinician by fax as soon as possible so we can schedule an appointment as necessary.

Referring Provider:_______________________________ Office #: _____________

Practice Name: _________________________________ Fax # _______________

Contact Person: ________________________________ Phone # _____________

Staff Provider if different from above: _______________________________________

Patient Name: _________________________________________________________

DOB: ___/___/______ Drivers License # _____________________

Mailing Address: _______________________________________________________
_______________________________________________________
_______________________________________________________

Home # _________________ Work: ________________ Cell: ___________

Primary Care Provider: ___________________________ Office: _________


___Evaluate and Treat Presenting Symptom/Diagnosis
_________________________
___ Physiological Test _________________________
_________________________
___ Eval and Refer _________________________

___ GAF Scale

Service/Appointment Status (Check all that apply)

___Urgent

___ Appt preferred on ________ (Day of week)

___ Appt preferred during AM or PM (Circle one)

___ Continued consultation with referring provider Referring Provider _________

Can the client you are referring meet the financial demand of 25.00 to 50.00 based on Medicare or Crisis Center Referral _____ Yes _____ No



Someone from our office will be in contact with you or the Patient to confirm receipt and date of scheduled appointments. Thank you for your referral and please do not hesitate to call or email us with any questions or concerns.

Sincerely

The Life Line Team
Edward A. DeSano III
200 1st Ave W, Suite 400
Seattle, WA 98109
O: (206)274-7861
F: (206)257-0584
P: 1(877)887-6191