referral Form

Client's Name*

First NameLast Name

Clients DOB

Referral Source *

ParentSelfcpsExternal Agency

External Agency Referral?

Referer's Name*

First NameLast Name

Phone Number*

Area CodePhone Number

E-mail

Best time to contact *

Reason for the Referral*

Other reason for referral (Please state below)

Please provide contact information for referral, such as The Client or guardian's name, number, or email.

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Please provide further information regarding this referral:*

Desired outcome:*

Relevant History ( any medications? a diagnosis? Is there a history of mental health illness within the family?)*

Please upload any paperwork relevant to this referral

Upload a File

Name of Insurance and Insurance Number *

Has the family had any CPS involvement?*

Parent or self Consent? Parents will be contacted regarding this referral. Individual Counseling can only take place with parental/guardian consent.*

YesNo

Is the client aware of the referral?*

YesNoUnsure

Privacy and Confidentiality Disclosure All information shared with the Counselor is confidential, meaning the child and family's information will not be shared with a third party without prior parental consent. There is, however, limits to confidentiality. These limits to confidentiality include: - counselors, like other Department of Education (DOE) staff, have a certain duty of care obligations to all students. Counselors are mandatory reporters of child abuse and neglect. As specified under Part 5.1 A of the Care and Protection of Children Act 2007. - If the School Counselor reasonably believes that the student/client is at risk of harm to themselves or others, she has a duty of care to report this to a mental health service or the police. - If it is disclosed to the counselor that the student/client has engaged in a crime or is going to become involved in such an activity, the counselor will need to contact the proper authorities. Please note:Turner Mental Health Counseling will always consult with parents prior to any information being shared with a third party, such as an external agency or teacher. We will only share information with a third party if it is in your child's best interest. Counselors and Case Managers are required to keep a file for each student being seen. These files are kept in a secure database. If you have any questions concerning Privacy or Confidentiality, please contact Turner Mental Health Counseling at 502-994-6118.

Turner Mental Health-Referral Form