Behavioral Health Referral Form
Date:
*
-
Month
-
Day
Year
Date
Client Legal Name:
*
First Name
Last Name
Preferred Name:
*
Client Date of Birth:
*
-
Month
-
Day
Year
Date
Client Social Security Number
Gender Identity
*
Primary Language:
*
Preferred Language:
*
Insurance ID #:
*
Insurance Provider
*
Check Yes if Medicaid
*
Yes
No
Guardian Name:
*
First Name
Last Name
Guardian Preferred Language:
*
Guardian Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian Email:
*
example@example.com
Client/Guardian Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Client:
*
If self-referring, please type "Self"
Parent Name (if different):
*
First Name
Last Name
Person Completing This Referral
*
Self
Parent/Guardian
Other/ Service Provider
Service Provider Name:
*
First Name
Last Name
Service Provider Agency
*
Service Provider Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Service Provider Email:
*
example@example.com
Has the family voluntarily agreed to this referral?
*
Yes
No
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Service Being Requested (Check All that Apply):
*
In-Home and Community-Based Therapeutic Services*
Office-Based Therapeutic Services*
Telehealth Therapeutic Services*
*Services are based on Insurance Coverage
Reason for Referral/Goals (Symptoms, Behavioral/Social/Emotional Functioning of Youth/Family, Focus of Treatment):
*
Has a behavioral health referral been placed to another agency at this time?
*
Yes
No
Has The Client Received Behavioral Health Services Previously?
*
Yes
No
Select if Currently Receiving Services
Please list all Psychiatric Hospitalizations, Crisis Visits, or Risk Assessments that have occurred in the past (1) one year:
*
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Client Risk for Re-Hospitalization (1=very low, 3=moderate, 5=very likely):
*
1
2
3
4
5
No Risk or Hospitalization History
At-Risk Factors of Safety Concerns Present (please choose all that apply):
*
Suicidal Ideations
Suicidal Gestures
Self-Injurious Behaviors
Homicidal Ideations
Current Substance Use
History of Substance Abuse
Running Away
Violence/Aggression towards others
Lack of Social Group
Isolates
School Refusal
Gang Involvement
Sexualized Aggression and/or Behavior
High Risk Sexual Activity
Takes Dangerous Risks
Fire-Setting
Medication Compliance Issues
Medical/Physical Condition
Other
Explain Client Medical/Physical Condition or Other At-Risk Factors
History of Trauma/Stress
Guardian Risk Factors (please choose all that apply):
*
Current Substance Use
History of Substance Abuse
Medication Compliance Issues
Housing Instability
Financial Distress
Current Domestic Violence
History of Domestic Violence
Unable/Unwilling to Provide Adequate Supervision
Lack of Natural Supports
Mental Health Diagnoses
Medical/Physical Issues
Other
None
Explain Caregiver Mental Health History, Medical/Physical Issues, or Other At-Risk Factors Present:
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Existing Diagnoses
*
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Current Providers (DSS, ACS, Preventative Services, Foster Care, Psychiatry, Individual Therapist, School Counselor, etc):
*
Client Current Medications
*
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Safety Concerns for Home/Community-Based Services (please choose all that apply):
*
Current Domestic Violence
Violent Family Member or Person Involved with Family
Lack of Safe Parking Available
Animals
Suspected Illegal Substances in Home
Weapons in Home
Known Neighborhood/Building Safety Concerns
None/Not Applicable
Other
Provide details for Safety Concerns Selected Above
How did you hear about Northeast Family Service?
*
NFS Website
Friend or Family
Referred by another agency
Other
Submit
Should be Empty: