Refer a client

This form should be completed by the VRC making the referral. Please provide as much information as possible so that we can provide you with the best possible service. If you have multiple clients, please submit a separate form for each client.

VRC Info

Referring VRC Name *

Referring VRC Email *

Preferred method of contact *

EmailPhone

Referring VRC Phone *

Client Info

Client name *

Please enter the LNI claim number(s) associated with the client you are referring. *

Please provide a copy of the Client's "Current Claim Status" Screen from the Claim and Account Center (CAC). *

Please provide a copy of the Client's "Addresses and Contacts" screen from the Claim and Account Center (CAC). *

Please upload the Client's BHI approval letter or chart note from the Attending Provider *

Client's Date of Birth

Client's Email Address

If client is attending PGAP, please provide Activity coach name

Languages spoken

Client's Gender Identity

MaleFemaleOther

Has the client received BHI or mental health services on this claim before?

YesNoDon't know

Please give a brief history or background of the client, attending provider goals and client concerns

Please attach any progress reports or notes from the claim file that may be helpful for the therapist to understand the client's therapeutic needs

Attached file 1

Attached file 2

Attached file 3

Attached file 4