Gordon S. Leith
Licensed Professional Counselor (LPC)
P. 210.590-9292
Fax 210.568.4663
www.gordonleithlpc.com
gordonleith@yahoo.com
CLIENT REFERRAL FORM
Date ____________________
Name of person to be referred _____________________________________
Parent or Guardian Name: ________________________________ Contact Ph. #_____________________
Street address__________________________________________________
City Zip___________________________
Phone ____________________________
Age & Date of Birth ____________________________
Social Security Number _______________________
Medicaid Recipient? _____YES _____NO Medicaid Number:____________________
Other Insurance? _____YES _____NO Insurance Name_________________________
Private Insurance Member ID _______________________________________and/or Private Insurance Group
ID_________________________________________
Referring Agency: __________________________________ Agency Contact Person:___________________
Referring Party Contact P. Number: _______________________ Fax: ______________________________
Alternate Ph. # ______________________ Address: ____________________________________________
Zip Code ________________________________
Reason(s) for referral______________________________________________________
________________________________________________________________________
________________________________________________________________________
CONFIDENTIALITY NOTICE: This communication may contain privileged and confidential health information, which is protected by state and federal statutes,
rules, and regulations. You are prohibited from making any further disclosure without the specific written consent of the person to whom it pertains, or as
otherwise permitted by law. If you are not the intended recipient or entity, be aware that any disclosure, copying, distribution, or use of this information is
prohibited. If you have received this communication in error, please notify us by return fax or telephone immediately so that we can arrange for the retrieval or
destruction of the documents.