Client Referral Form

Thank you for your referral. We appreciate your partnership in connecting clients with our practice.

This form is intended for healthcare professionals and community agencies referring clients for mental health services. Please complete all applicable sections to support timely and appropriate care.

Additional information about our services and referral process is available on our website.

If you have any questions or require assistance, our administrative team can be reached at (813) 937-9310 or via email at hello@livepurposelycs.com.

We look forward to collaborating with you and supporting your clients.

Client Information

First Name

Last Name

Date of Birth

Age

Phone Number

Email Address

Has The Legal Guardian Been Informed Of And Consented To This Referral For Mental Health Services?

Yes No

Guadian Full Name & Relationship To Client

Other (please specify)

Insurance Company

ID Card Number

Group Number

Customer Service / Provider Line Phone Number

Employee Assistance Program (EAP)

Prior Authorization Number

Number of Uses

Valid To / From Date

Other (please specify)

Referral Source

Name of Referral Source

Relationship or Agency

Phone Number of Referral Source

Email Address of Referral Source

Reason For Referral

Do You Have a Signed Authorization for Release/Request of Information (ROI) For This Client? Please ensure that the client has provided informed consent for sharing relevant information with our practice before submitting this referral.

Yes No

Upload The Authorization For Release/ Request of Information.

Add file

Please upload a file

If No, I Understand That We Will Not Be Able to Share Information Regarding the Referral or The Client’s Care.

Please obtain the client’s consent before contacting us for any updates.

Questions or Comments (Optional)

Other (please specify)

Provider Name

Agency Name

Your information will be encrypted.