Impact Community Resources Behavioral Health

Impact Education & Career Counseling

Referral Form

Person Completing Referral
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Agency
Is this Individual aware of this Referral?

YesNo

Individual Information
Demographic*

ChildYoung Adult (18-27)AdolescentAdult (27+)
Individual Primary Language

EnglishSpanishOther
Individual Gender*

MaleFemale
Does this Client have a Payee?

YesNo
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Last 4 of SSN
Phone Number
Please enter a valid phone number.
Source of Income*

WagesSSI/SSDIRetirement IncomeVeterans Benefits
Is this Client Homeless or at risk of being homeless?*

YesNo
Does the Client have insurance?*

YesNo
Insurance
Group Number
Member ID Number
Does this Client have a legal Guardian?*

YesNo
Parent/Guardian Name (where appropriate)*

NamePhoneRelationship
Address (if any)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Services Requested (Check All that apply)*

Mental Health CounselingChild/Adolescent Outpatient ServicesSubstance Use CounselingStudent/Parent AdvocatePayee ServicesNominee TrusteePeer SupportCommunity NavigationPeer Support TCLCommunity NetworkingEmployment AssistanceSupportive Housing AssistanceLong Term Support ServicesTransitional HousingIndividual and Transitional Supports
Has this Client been approved and/or currently receiving any of the following housing subsidies/vouchers?

TCLHUD VashRapid RehousingPublic HousingSection 8
Is the Client currently working with any of the following Community Providers?

TCMPeer SupportPeer Support TCLCommunity NavigatorCST (Community Support Team)ACTT (Assertive Community Treatment Team)None of the Above
Select all applicable challenges below for the Individual referred (check all that apply)

Ability to avoid dangers/hazardsAnger ManagementAnxiety/PhobiasCommunity Linkage of ServicesCommunication & Social SkillsDepressionGriefHousingHygieneImpulsive BehaviorsJuvenile Justice/Court InvolvedHealth & Life SkillsFinancial ManagementMedication EducationNutritionalPRTF/Hospital DischargeUnsafe living environmentSchool behavioral IssuesSelf-Advocacy SkillsSelf-Harm or Harm to OthersSeparation IssuesSubstance UseSustainable employmentPTSDTruancyYouth to Young Adult TransitionOther
Should be Empty:

Impact Education & Career Counseling