Mental Health Referral Form
Information about Parent or Person Completing Referral
Name
*
First Name
Last Name
Relationship to client
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent / Guardian Name, if different from above
First Name
Last Name
Parent / Client Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Parent/ Guardian Email, if different from above (Initial paperwork will be sent here)
example@example.com
Parent/ Guardian Phone Number, if different from above
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Individual aware of this Referral?
Yes
No
Please indicate the type of insurance that patient holds, if any (if Medicaid, please specify - Aetna, Passport, Humana, UnitedHealth, or Wellcare)
*
Client's Pediatrician
Medicaid ID or SSN (if you do not know, you can complete later with initial paperwork)
Type of Services Needed (check all that apply)
*
Child Outpatient Therapy (ages 4-12)
Adolescent Outpatient Therapy (ages 13-19)
Adult-ish Class (basic life skills, social emotional learning, etc)
Case Management (housing, food, school help, clothing, job exploration)
Peer Support Specialist
Summer program
Parenting counseling & education
Autism Assessment (please note that you will be placed on our waitlist and will be contacted when a space becomes available)
Home School Program (Friendship Lab)
After School Program (located on College Street)
Play it Forward Sports Program
Sister Circle
Other
School that client attends
Individual Gender
*
Male
Female
Other
Individual Primary Language
*
English
Spanish
Other
Reason for Referral (please note if you have a specific clinician that you would like to work with)
*
List allergies, if applicable
Current Medications (if known or applicable)
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
Depression
Grief
Housing
Hygiene
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
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
Family Conflict
Other
Submit
Should be Empty: