Referral Form for an Adult

230 North Limestone, Suite 100 Lexington, Kentucky 40507
(859) 303-8041 office@heatherriskandassociates.com

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If you would like to refer yourself or another adult, please complete the information below. This information will help Heather Risk, PsyD & Associates, PLLC in ensuring you needs are met. After receiving the following information, we will contact you to discuss any questions and take the next steps to beginning services.

Today's Date:

Client's Name: *

Gender:

Female

Male

Other:

Date of Birth:

Age:

Address: Street, City, State, Zip Code:

Work Phone: ### - ### - ####

Can we leave a message at this contact? (Work)

Yes

Cell Phone: ### - ### - ####

Can we leave a message at this contact? (Cell)

Yes

Home Phone: ### - ### - #### *

Can we leave a message at this contact? (Home)

Yes

Email Address:

Emergency Contact Information

Who can we contact in case of an emergency?

Name:

Phone: ### - ### - ####

Relationship

Who is completing this form?

Self

Other:

Name:

Relationship

Phone: ### - ### - ####

Email:

Why are you seeking an assessment and/or treatment? Please be as specific as you can as you explain your concerns, when the concerns began, and your goals for services:

Have you (or the person you are referring) experienced any history of trauma, abuse, or maltreatment? If so, please explain:

Have you (or the person you are referring) ever made any suicide attempts or demonstrated violent behavior? If so, please describe (age, reasons, circumstances, behaviors, etc.):

Have you (or the person you are referring) received therapy in the past? If so, please provide a brief description of the services received, reason for services, provider or agency name, and why services ended):

Specify any medication you (or the person you are referring) are currently taking and for what:

Is there any additional information you think we should know before beginning services? Do you have any questions?

Referral Form for an Adult

Emergency Contact Information

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