Referral Form Referring Therapist Name(Required)Referring Therapist Email(Required) Referring Therapist Phone(Required)Patient First Name(Required)Patient Last Name(Required)Age(Required) Adult 18+ Female Adolescent 13-17 Phone(Required)Please select(Required) Self Pay Insurance Unknown Has your referral already been in contact with Honey Lake Clinic admissions department?(Required) Yes No Which is the best date for admissions to reach your client by phone?(Required) MM slash DD slash YYYY What is the best time for admissions to reach your client by phone?(Required) Morning 9-11 am Lunch 12-2 pm Evening 3-7 pm Δ