Mental Health Agency Referral Form
For use by referral agencies to refer individuals for mental health services at Kids Hub Child Advocacy Center. If you are a parent or caregiver interested in mental health services, please use the "Request Mental Health Services" form.
Referral Date
*
-
Month
-
Day
Year
Date
Referral Agency Name
*
Referring Agency Contact Person
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
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Client(s) Information
Name of Individual(s) Being Referred and Date of Birth
*
Insurance Provider
*
Please Select
Medicaid
Private Insurance
Uninsured
Other
If you selected "Private" or "Other" please list Insurance Provider below.
Legal Guardian's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Guardian's relationship to the Individual(s) being referred.
*
Please Select
Parent
Foster Parent
Grandparent
Aunt/Uncle
Other
If you selected "Other" please provide relationship below.
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Reason for Referral
Is this referral due to victimization
*
Yes
No
If yes, type of victimization
*
Please Select
Sexual Abuse
Physical Abuse
Neglect
Witness to Violence
Kidnapping
Drug Endangerment
Other
If you selected "Other" please provide type of victimization below.
Mental Health Services Request (check all that apply)
*
Trauma- Focused Therapy
Crisis Intervention
Psychological Evaluation
Behavioral Therapy
Individual Counseling
Problematic Sexualized Behavior
Other
Brief Description of Concerns/Reason for Referral
*
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Additional Information
Is the Legal Guardian aware a referral has been made to our agency for mental health services?
*
Yes
No
Are there any current safety concerns (self-harm, harm to others, etc.)?
*
Yes
No
Unsure
If yes, please provide details below
Has the client received previous mental health services?
*
Yes
No
If yes, please provide details below
Please provide any documentation that may be helpful for scheduling purposes (i.e. court orders for services and/or assessments, legal guardianship paperwork)
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