Make a Referral | Family Legacy Health & Wellness Center

Client Referral

This form can be submitted by providers, family members, community partners, courts, schools, or anyone seeking to connect a person with our services. Fields marked * are required.

Section 1 — Client Information

Client First Name *

Client Last Name *

Date of Birth *

Gender / Pronouns

Client Address

City, State, Zip

Client Phone

Client Email

Insurance Provider

Medicaid / Insurance ID Number

Section 2 — Referring Party Information

Your Name *

Your Relationship to Client

Organization / Agency

Your Phone *

Your Email *

Section 3 — Clinical Information

Services Requested Hold Ctrl (Windows) or Cmd (Mac) to select multiple.

Presenting Concerns / Reason for Referral *

History of Mental Health Treatment

Current Medications (if known)

Safety Concerns

Additional Notes or Special Circumstances

Client Consent Obtained? *

Privacy Notice: Information submitted on this form is transmitted securely to our intake team at info@familylegacyhwc.com and used solely for the purpose of coordinating care. All information is subject to HIPAA privacy protections.

✓ Referral received! Our intake team will contact you within one business day to discuss next steps. Thank you for connecting this person with care.

There was a problem submitting this referral. Please call us directly at (216) 555-0000 or email info@familylegacyhwc.com to complete the referral.

Client Referral Form

Client Referral

Section 1 — Client Information

Section 2 — Referring Party Information

Section 3 — Clinical Information