Online Referral Form

Referring Agency: *

Are you licensed? (examples - LCSW, LMSW, LPC, LBSW, M.D., RN, etc.) If no, please indicate on the next line the licensed practitioner at your facility concurring with and recommending this referral to Lowenstein House. *

Yes, I have a professional license

No, I am not licensed, however, the following licensed practitioner recommends this referral to Lowenstein House:

Client's Social Security Number *

Why does the person want to come to Lowenstein House? Check all that apply. *

Needs structured activity during the day

Wants to obtain job skills and/or employment

Needs to develop illness management and/or mental health recovery skills

Needs housing and/or independent living skills training

Needs social skills development

Needs to develop activities of daily living skills

Other - indicate in the comments section below

Name, Title and Credentials of Referring Person (please include your degree and/or license) *

Client's Primary Diagnosis / ICD-10 Code *

Phone Number of Referring Person *

Race *

Black or African-American

Caucasian

Other

Referring Agency Address *

Client's Address *

Source of Income *

No income

Social Security Disability (SSDI)

Supplemental Security Income (SSI)

Other

Does client have Tenncare? *

Yes

No

Unknown

If Client has TennCare, indicate the name of the BHO:

If No is checked above, indicate the name and credentials of the licensed practitioner authorizing this referral to Lowenstein House:

Client's Date of Birth *

Client's Name *

Current Medications

Client's phone number *

Sex *

Male

Female

Comments