Behavioral Health Referral Form
For Their Strength Companionships for Mental Health Please note that Their Strength Companionships for Mental Health LLC will make three attempts to contact the referred family. If we are unable to reach them, we will then contact you, the referring professional, to inform you of the situation. We will also send an email and provide a direct update on the status of the client's intake or services. You are welcome to reach out to us at any time for an update on your referral.
Information about Person Completing Referral
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Agency:
CPS
FBSS
Other Case Management Provider
Other
Self Referral
CPS CVS
CPS/FBSS Supervisor Name: (CPS/FBSS Only)
First Name
Last Name
Supervisor Email
example@example.com
Supervisor Phone Number
for contact once case is closed.
Format: (000) 000-0000.
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Insurance number:
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client/Family Insurance Provider:
*
Texas Children's Health Plan (Star)
Community Health Choice
Molina Health Plan
Superior Health (STAR)
No Insurance (Pro-Bono)
Other Insurance (Pro-Bono)
Type of Referral :
*
Resource for closure (Client do not need to engage in services. This is just a resource)
Involvement (The clients NEED to work services)
Court Mandated (The client has a court order to engage)
Mental Health Services (Not FBSS/CPS related)
Court Involvement Services (PMC/TMC)
Is Individual aware of this Referral?
Yes
No
Does the client have an open CPS, CVS or FBSS case?
*
Yes, FBSS
Yes, CPS
Yes, CVS
No open case
Not Sure
Pending Closure
If CPS Case Open. Is the Case/family labeled as a " HIGH RISK"
Yes
No
No open Case
Parent/Guardian Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
How many children are in the home?
Please provide the children in the home or case information for our record:
Child #1 Name:
First Name
Last Name
DOB:
-
Month
-
Day
Year
Date
Child #2 Name:
First Name
Last Name
DOB:
-
Month
-
Day
Year
Date
Child #3 Name:
First Name
Last Name
DOB:
-
Month
-
Day
Year
Date
Child #4 Name
First Name
Last Name
DOB:
-
Month
-
Day
Year
Date
Child #5 Name:
First Name
Last Name
DOB:
-
Month
-
Day
Year
Date
CPS/FBSS: Do children and Parent need services?
Yes
No
Maybe
Specify service Individual/ Family is needing? ** Please make sure services are not already being provided by other providers**
*
Case Management (CM)
Family Skills and Development
Teen Pregnancy Program
Individual Therapy
Intensive Case Management (ICM)
Medication Case Management
Parenting Classes
Psychosocial Rehabilitation - Individual (PSRI)
Mental Health Evaluation
Supported Employment
Substance Use/ Alcohol abuse services 90days
Homelessness Support Services
Supportive Parenting Program for Parents with Intellectual or Neuro Disorders
Child/Teen Mental/Behavioral Skills and Development
Individual Primary Language
English
Spanish
Other
Reason for Referral/ Concerns that needs to be address in services:
*
Please provide details for the reason the individual is needing services
Current Medications
FBSS/CPS Please provide a summary of " Reason for Intake". What is the reason the family has a open CPS/FBSS case. (The agency need to understand past history and concern that got the family/individuals a open CPS/FBSS case)
*
This is to help our agency assist services .
Select all applicable challenges below for the Individual referred (check all that apply)
Ability to avoid dangers/hazards
Anger
Anxiety
Community Linkage of Services
Daily living skills/Life Skills
Depression
Grief
Housing
Hygiene
Impulsive Behaviors
Juvenile Justice/Court Involved
Teen Parenting/Pregnancy
Maintaining personal affairs
Medication Education
Nutritional
Phobia/s
PRTF/Hospital Discharge
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Sustainable employment
Trauma
Truancy
Whole Health/Wellness
Youth to Young Adult Transition
Mental Health disorder (not being addressed)
Other
I understand that Housing is not a single service and the family has to patriciate in services to be eligible.
*
Yes, I understand
No, I do not understand
I understand that without in detail information about the client or family case or concerns TSCMH will only provide the services that the agency see fit.(Meaning: If the referral only state counseling this will be the only service provided by the agency).
*
Yes, I understand
No,I do not understand
I understand that if the client or family is actively receiving services from another Mental Health Agency (Ex: The Harris Center, AOC, Texana) Their Strength Companionships CAN NOT provide services.
*
Yes, I understand
No, I do not understand
Their Strength Companionships for Mental Health LLC
Office: 346.241.9440 Fax: 832.202.1349 Email: info@Theirstrength.com
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