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
2 digit month, 2 digit day, 4 digit 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
What time of day do you prefer appointments?
*
Morning
Afternoon
Either
Weekends (when available)
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 your child attends, if applicable
Do you want school based therapy for your child, if we are able
Yes
No
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: