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.