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Referrer Information

Referrer Name(Required)

First Last

Referrer Phone(Required)

Referrer Email(Required)

Service(Required)

Assessment/Screening

Medication Management

IT/FT/Group Therapy

Patient Information

Patient Name(Required)

First Last

Patient Phone(Required)

Patient Email(Required)

Patient Primary Language(Required)

Date of Birth(Required)

Month

Day

Year

Patient Gender(Required)

Patient Address(Required)

Street Address Address Line 2 City State ZIP Code

Patient Race(Required)

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Patient Ethnicity(Required)

Hispanic or Latino

Other

Check All That Apply(Required)

Dangerous Behaviors

Substance Use/Abuse

Thoughts of Suicide/Homicide

Problems at School

Family Problems

History of Abuse/Neglect

Brief History/Presenting Problem(Required)

Parent/Legal Guardian

Add Parent or Legal Guardian?

Yes

No

Guardian Name(Required)

First Last

Guardian Phone Number(Required)

Guardian Primary Language(Required)

Is the parent/legal guardian and patient address the same?(Required)

Yes

No

Guardian Address(Required)

Street Address Address Line 2 City State ZIP Code

Patient Primary Care

Primary Care Office(Required)

Physician(Required)

Physician Phone Number(Required)

Physician Address(Required)

Street Address Address Line 2 City State ZIP Code

Δ

2406 Madison Drive
North Myrtle Beach, SC 29582

Phone: (843) 663-0748

Fax: (843) 663-0749

Email: referrals@lifespancare.net

South Carolina Office

North Carolina Office

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