Provider Name *

First Name

Last Name

Provider Type *

Primary Care Physician

Therapist

Psychiatrist

Case Manager

Registered Dietitian

Coordinator

Other

Provider Phone *

(###)

###

####

Client / Patient Name *

First Name

Last Name

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

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