Request Referral For Outpatient Services... Click Here

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(252) 527-3300

Outpatient Request

Home
About Us
Services
Appointment
Contact

[email protected] (252) 527-3300

Home
About Us
Services
Appointment
Contact

Request Referral For Outpatient Services

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Request Referral For Outpatient Services

Patient Information:

Date:

Patient Name: *

First

Last

Patient ID Number: *

Patient Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Phone Number: *

Email: *

Insurance Information:

Primary Insurance: *

Policy Number: *

Insured Name: *

Secondary Insurance:

Primary Insurance: *

Insured Name: *

Primary Care Physician: *

PCP Address: *

Address Line 1

Address Line 2

City

State

Zip Code

PCP Office Number: *

Prescription for: *

Outpatient Therapy Individual
Outpatient Therapy Group
Family Therapy
Psychosocial Rehabilitation
Substance Abuse Treatment

(Please select Outpatient Treatment)

Diagnoses: *

Behavioral Health Services for: *

Individual Outpatient Therapy
Diagnostic Assessment
Psychiatric/Medication Evaluation
Comprehensive Clinical Assessment
Medication Management
Individual and Family
Substance Abuse Evaluation

Behavioral Health Services for:

Relevant presenting problems: *

Previous Assessment or Evaluation? *

Yes
No

If yes, date: *

Previous MH/SA Treatment? *

Yes
No

If yes, date: *

Life Touch, LLC purpose is to promote optimal mental health, social, emotional and character development for children, youths, adults and families.

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Location 1

Contact No.(252) 527-3300
Fax No.(252) 527-6200
2111 North Queen St, Ste 2. Kinston, NC 28501

Location 2

Contact No.(919) 330-4090
Fax No.(919) 759-5012
405 E Walnut Street Goldsboro, NC 27530