Screening Form

Cosby Counseling & Consulting, PLLC Residential Screening Form

Please note this form must be completed for all referrals to the outpatient (group and individual counseling services).
Date

MonthDayYear
Date
Youth's Full Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Referral Source
example@example.com
Anticipated length of need
Current (within the last 30 days)
Current Setting
Any concerns in the following areas: (If requesting residential level 3 services please complete. A physical/ health screening completed within the last 30 days is also required prior to admission)
Additional Information
Should be Empty:

Cosby Counseling & Consulting, PLLC Residential Screening Form