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For questions regarding your referral, contact the office.

An intake appt will be scheduled to be held within 10 days from the date of referral

Client Referral Form

Date of Referral: _____________________

Referral Source: _____________________________________

(caseworker)

_____________________________________

(Supervisor)

_____________________________________

(name of organ./title)

_____________________________________

(work number/ cell number)

_____________________________________

(email address)

General Client Information:

Name:___________________________________DOB:__________Race: ________________

Parent/Guardian name: ___________________________________________________

Address:______________________________________________________________________

City:___________________Zip:_____________ Phone: (h)____________________________________

(Work) _____________________________ (Cell) ____________________________________________

MD Medicaid #:___________________________Social Security#_______________________

Legal Guardian Name (For Signature Purposes): ____________________________________

Work & Cell Phone;_________________________________________

Email Address:

Services requested:

_____ Individual therapy _____ Mentoring (one-on-one)

___ Clinic ___ No. of hrs. per week

___ Home Based

______ Family Therapy ______ Tutoring (one-on-one)

____ Clinic ___ No. of hrs. per week

____ Home Based

_____ Psychiatric Evaluation

_____ Group Therapy _____Medication Mngmt.

______ Psychological Eval ___ Psychosexual Eval ___ Psychoeducational Eval

PresentingProblems/Concerns for Treatment: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Brief Psychiatric./Medical History (medication prescribed): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Risk Assessment:

Symptom: yes no Comments:

Suicidal thoughts [] [] ____________________________________

Plan [] [] ____________________________________

Previous Attempts [] [] ____________________________________

Danger to self [] [] _____________________________________

Homicidal Thoughts [] [] _____________________________________

Homicidal Actions [] [] _____________________________________

Ever Been Arrested

Fears Consequences [] [] ____________________________________

Command Hallucinations [] [] _____________________________________

Danger to others [] [] _____________________________________

Poor Impulse Control [] [] _____________________________________

Poor Social Supports [] [] _____________________________________

Sexual Misconduct [] [] _____________________________________

Willing to Accept Help [] [] ______________________________________

Danger to self: low [] moderate [] high []

Danger to Others: low [] moderate [] high []

Signature:_________________________________________________

****Fax to 1-866-371-5933 along with copy of most recent court report, psychiatric or psychological report, and/or IEP as is appropriate….

Do not write below this line: Office use only

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Assigned To/Date of Assignment:

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Comments:

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