Family Solutions USA - Referral Form

Referral Form

Hey there! We're so glad you're here at Family Solutions! Taking the first step towards taking charge of your mental health is a huge accomplishment, and we're here to cheer you on every step of the way. Whether you're looking for a friendly chat to explore some options, or you're ready to dive headfirst into beginning our program we've got you covered. This referral form is the first step to improving your life. Once you have completed this form we'll get you matched up with a case manager or therapist to help you reach your goals. Let's get started! If you have any questions or issues while completing this form please call us for assistance.
Today's Date

MonthDayYear
Date
Client Demographics
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Marital Status:
Race:
Ethnicity:
What is the client's primary language?
Sex:
Veteran:
Social Security Number:
Type of Insurance or Payment Method
Insurance Provider:
Insurance Number:
School (if applicable):
List Full Name of School and School District or N/A.
Last Grade or Degree Completed:
Client's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client Email:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's current living situation:
Reason for Referral:
Needs/Risk Assessment/Behavior (Check all that apply):
When assessing the needs, risk, and behavior of presenting symptoms, the following factors are commonly considered. Please check all that apply:

Other
Does the client currently use nicotine or tobacco products?
If yes, please specify (e.g., cigarettes, vaping, chewing tobacco):
Parent or Legal Guardian Information
Parent/or Legal Guardian (if applicable):

First NameLast Name
Email
example@example.com
Mobile Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Alternative Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Please indicate whether the contact information above is for the client’s legal guardian or biological parent.

Other
If you are not the biological parent of the child, can you provide one or more of the following documents to verify legal guardianship? 1) A copy of the child’s birth certificate showing your name, 2) A legal custody agreement, 3) A court order establishing guardianship, 4) A notarized power of attorney for guardianship, 5) Adoption paperwork, 6) Affidavit of guardianship, 7) Foster care placement documents (if applicable), or 8) School enrollment forms listing you as guardian (may be used in conjunction with another document)
What is the legal guardian/biological parent preferred language?

Other
Referral Source Contact Information
Name of Person Submitting Referral Form:

First NameLast Name
Relation to the client
Ex: Parent, Relative, Spouse or Professional Support
Individual or Agency
Write self-referral if you are referring your child or guardian. Otherwise, please list the name of the company or school you work for.
Referral Source Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Referral Source Email:
example@example.com
For a minor client, was the Parent or Legal Guardian notified of this referral?:
Does the Client Receive Services From Another Mental Health Provider? (If so, they need to be discharged from their current provider)
Are the Services Currently discontinued?
Has the client been hospitalized or participated in a Partial Hospitalization Program (PHP) or Intensive Outpatient Program (IOP) within the last 30 days?
Clients Primary Care Provider Name:
Primary Care Providers Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Provider Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Which office location is closest to you? Please choose one.
How did you hear about us?

Other
Which Family Solutions USA staff assisted or referred you to our program?
Please list their full name and office location.
Next Steps with Family Solutions
Which of these weekdays works best for your intake appointment?
Select one or multiple available timeslots for an intake appointment.
Where would you like your appointment to take place?
Should be Empty:

Referral Form

Client Demographics

Parent or Legal Guardian Information

Referral Source Contact Information