Illustrious Angels Youth and Family Services Referral Form
Children 17 and under
Client Name
First Name
Last Name
Client Email
example@example.com
Client Phone Number
Please enter a valid phone number.
Client Date of Birth
-
Month
-
Day
Year
Date
Age
Gender
Ethnicity/Race
White/Caucasian
Black/ African American
Native Hawaiian or other Pacific Islander
Asian
Hispanic or Lationo
Other
Grade Level
Guardian Name
First Name
Last Name
Guardian Email
example@example.com
Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian Phone Number
Please enter a valid phone number.
Relationship to Child
Biological parent
Adoptive parent
Foster Parent
Other
Is this the child's legal guardian?
Please Select
Yes
No
Unknown
If No, who is the legal guardian?
Special Accommodation needed? If yes please list. If no, please put n/a
Is your child currently under the care of a professional counselor?
Please Select
Yes
No
Referring Agency Name
Referring Agency street address
Referring Agency town/state/ zipcode
Referring Agency phone number
Please enter a valid phone number.
Referring Agency Email
example@example.com
Referral prepared by:
Parent or Gaurdian
Intervention Specialist
Advocate
Social Worker option 4
Other
Do you have the caregivers permissions to make the referral?
Please Select
Yes
No
Reason for referral. Check all that applies.
Domestic Violence Individual
Domestic Violence Family
Child Abuse
Sexual Assault
Sex Trafficked
Teen Dating Violence
Victim of Violent Crime
Other
Does the client experience the following? Check all that applies.
Low self esteem
High levels of Depression
Poor school performance
Anxiety
Fighting with others
Defiant Behavior
Temper Tantrums
Suicide Idelations
Self-mutilation
Anger and / or lack of social sills
Other
Please describe any other concerns that have led to this referral. Please indicate if referral is urgent and why.
Do you have insurance?
Please Select
Yes
No
Recipient
First Name
Last Name
Medicaid#
Insurance Company Name
Policy Number
Policy Begin Date
Policy End Date
Group Number
Insured First/ LastName
Employer’s Name
Employer’s Address
City
State
Gaudian/ Caregiver/Referring Agency Signature
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