New Client Referral Form

Our counselors work with children as they heal from the emotional impact of domestic violence witnessed or experienced. If you are interested in our services, please complete all of the following and a program representative will contact you for an initial phone screening. Our counseling services are *voluntary and free of charge.
Eligibility Requirements for Counseling Services - You must be able to answer "Yes" to all 4-questions:*

1)Yes, the survivor has at least one child between the ages or 0-12 yrs. *(We serve children 0-12yrs with their parent/caregiver only.)2)Yes, the survivor & child/children can schedule their family’s counseling sessions between 9am to 5pm (Mon-Fri)3)Yes, the survivor is no longer in the abusive relationship4) Yes, this request is solely for Counseling Therapy; *Not for suicidal thoughts or urgent/emergent crisis; Not Court, County, or State Mandated Services. *PCTS Counselors do not attend court and will never provide family or parental fitness reccomendations
*For potential suicidal thoughts, abuse or mental health crisis Contact 911 or an appropriate agency.
- CARE NW (503) 276-9000 -or- (503) 413-2200
- Oregon Child Abuse Hotline 1-855-503-SAFE (7233)
- Suicide Hotline (800) 273-8255
- Multnomah County Mental Health Crisis Line (503) 988-4888
*Unable to to answer "Yes" to all Requirements?

Contact 211 in your County or 1 (866) 698-6155 to learn of resources in your area
Services Requested:*

Counseling for a Child (*Must answer "Yes" to all 4-requirements above)Support Groups or Class (*ONLY if directed by PCTS Staff)
Contact Information
Referring Organization (*or write in "Self" if this is a Self Referral)
Referring Staff Member Name

First NameLast Name
Referring Organization Phone Number

Area CodePhone Number
Impact NW Counselor(*If Known)
Child's Name (Primary Client)*
Race & Ethnicity of Child (Primary Client)*
Child's Date or Birth (Primary Client)*
Languages of Child (Primary Client)*
Parent/Guardian Name
Parent/Guardian's Cell Phone

Area CodePhone Number
Parent/Guardian's Zip Code
Parent/Guardian's County
Race & Ethnicity of Parent/Guardian*
Parent/Guardian Email
example@example.com
*Communication with Parent/Guardian*

Safe to call the number provided?Safe to text the number provided?Safe to email address provided?
Languages of Parent/Guardian*
Date Submitted*

MonthDayYear
Space is Limited

Please note, space is limited. Allow no less than 2-weeks for review. One of our staff will contact the parent/guardian for a screening call.
Preferred Counseling Appointment Days & Times

What are the best times for you to meet weekly with a counselor?

	Monday	Tuesday	Wednesday	Thuraday	Friday
8am-10am
10am-12pm
12pm-2pm
2pm-4pm
4pm-5pm,

Random Generated Number*
Revised 10/2020
STAFF ONLY SECTION: Additional Comments, Notes, Contact Dates/Times
Should be Empty:

*Unable to to answer "Yes" to all Requirements?

Contact Information

Space is Limited

Preferred Counseling Appointment Days & Times