Referral/Intake Screening

IF SELECTED OTHER: PLEASE LIST REQUESTED SERVICE(S)

CLIENT NAME (FIRST NAME)*

CLIENT NAME (MIDDLE NAME)*

CLIENT NAME (LAST NAME)*

CLIENT MEDICAID/INSURANCE/POLICY HOLDER* (PROVIDE NUMBER)

CLIENT DATE OF BIRTH (MM/DD/YYYY)

CLIENT AGE*

CLIENT SEX

MALE

FEMALE

OTHER

CLIENT ADDRESS*

CITY*

STATE*

ZIP*

COUNTY*

CLIENT EMAIL ADDRESS*

CLIENT HOME PHONE*

CLIENT CELL PHONE*

PRESENTING PROBLEMS (PLEASE BE SPECIFIC INCLUDE DIAGNOSIS IF APPLICABLE)*

OTHER SERVICES CLIENT IS CURRENTLY RECEIVING*

REFERRAL SOURCE NAME AND TITLE*

REFERRAL PHONE*

REFERRAL EMAIL PHONE*

ARE YOU THE LEGAL GUARDIAN OF THE CLIENT?

Yes

No

IF NOT, PLEASE LIST THE LEGAL GUARDIAN FULL NAME, EMAIL ADDRESS & PHONE NUMBER*

SUBMIT DATE*

UPLOAD SUPPORTING DOCUMENTATION FOR CLIENT

Upload File

TRANSITIONAL THERAPEUTIC SERVICES, PLLC

Phillip White, Owner/Founder

943 W. Andrew Ave Suite N

Henderson, NC 27536

referrals@transitionalts.com

Office Phone: 252-598-2462

Fax: 252-598-0956

Locations:

TRANSITIONAL THERAPEUTIC SERVICES, PLLC

Phillip White, Owner/Founder

300 Southtown Circle Suite 15

Rolesville, NC 27571

services@transitionalts.com

Office Phone: 252-598-2462

Fax: 252-598-0956

Other Locations:

"Don't allow your stumbling blocks to stop you...use them as stepping stones to

promote you to the next level."