Provider Name *

First Name

Last Name

Provider Type *

Primary Care Physician

Therapist

Psychiatrist

Case Manager

Dietician

Coordinator

Other

Provider Phone *

(###)

###

####

Is the client aware of and in consent of this referral? *

Yes

No

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

Medical records

Fax: 877-775-3306 Email: medical_records@lilium-center.com

Yes- via Email

Yes- via Fax

No or N/A

Contact you or patient as next step? *

Contact Me

Contact Patient