Professional Referral Form Professional Referral To Lilium Center Mental Health and Wellness Services Provider Name * First Name Last Name Provider Type * Primary Care Physician Therapist Psychiatrist Case Manager Registered Dietitian Coordinator Other Provider Email * Provider Phone * (###) ### #### Organization (if applicable) Client / Patient Name * First Name Last Name Client Date of Birth * Client Email Client Phone * (###) ### #### Client preferred method of communication? * Phone Email Either Client location preference? Edina Saint Paul Virtual Service(s) Interest * Individual Therapy Family Therapy Child Therapy Group therapy EMDR Therapy Wellness Services Diagnostic Assessment Insurance type (if known) Additional Comments Sending medical records with this referral? Yes- I am emailing records to medical_records@lilium-center.com Yes- I am Faxing records to 1-877-775-3306 No - I am not sending medical records Is the client aware of and in consent of this referral? * Please note that Lilium Center will ONLY contact the Patient directly with confirmation that they are aware of and consent to contact. Yes No Uncertain Should Lilium Center contact you or your patient as next step? * Please note that Lilium Center will ONLY contact the Patient directly with confirmation that they are aware of and consent to contact. Contact Me Contact Patient Thank you! We have received your referral and will be in contact with you or your client/patient within one business day. Thank you for your trust and continued partnership.For questions you can call us directly 763-703-4215
