Screening Referral Form

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We’re here to support your health and well-being journey. Please complete this simple form to refer a client for services such as outpatient therapy, clinical assessments, peer support, or substance abuse groups.

Once submitted, our compassionate team will review the referral promptly and guide both you and your client through the next steps with care, clarity, and a commitment to lasting success.

I FIT OUT SCREENING REFERRAL FORM

Please take a moment to fill out the form.

PLEASE CHECK THE TYPE OF SERVICE-REQUESTED * Required

OUTPATIENT THERAPY

CLINICAL COMPREHENSIVE ASSESSMENT

PEER SUPPORT

SUBSTANCE ABUSE GROUP

OTHER:

PLEASE BE SPECIFIC

COMPLETE CLIENT'S INFORMATION BELOW

Medicaid/HC/ Insurance #:

Type of Insurance:

Private Pay:

Client’s First Name:

Client’s Middle Name:

Client’s Last Name:

Client’s Home Address:

City, State & Zip:

County:

Client’s Date of Birth:

Client’s Social Security#

Client’s Age:

Clien'ts Phone/Cell:

Client’s Email Address:

Client's Sexual Orientation: *

Male

Female

Non-Binary

Prefer Not to Say

Other

Client’s Emergency Contact/Relationship:

Client’s Emergency Phone:

LEVEL OF GUARDIANSHIP - TO BE COMPLETED WHEN A CLIENT HAS GUARDIANSHIP OR COURT ORDERS.

Are you the legal guardian of the client?

Yes

Legal Parent/ Guardian Full Name:

Legal Parent/Guardian Email Address:

Legal Parent/ Guardian Phone:

Referral Source Name & Title:

Referral Source Phone:

Referring Agency Location:

Primary Care Physician & Location:

Physician Phone:

Previous Clinical Assessment or Psychiatric Evaluation (Circle)/Date:

Present Problems/ Reason for Referral:

CURRENT MEDICATIONS (FILL IN COMPLETELY OR INDICATE NA OR UNKNOWN)

1. Name/Dosage-Frequency/Date Prescribed/Prescribed by/Efficacy-Compliance

2. Name/Dosage-Frequency/Date Prescribed/Prescribed by/Efficacy-Compliance

UPLOAD SUPPORTING DOCUMENTATION FOR CLIENT

Upload File

Upload supported file (Max 15MB)

Submit Date: * required

Thanks for submitting!

Submit A Referral

I Fit Out, LLC

Monday – Friday: 8:30 AM – 5:00 PM

511 Martin Luther King Jr. Dr., Lumberton, NC 28358

Email: info@ifitoutllc.com Phone: 910.370.0018 After hours: 919.208.0671

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