REQUEST SERVICES

Date Received*

MonthDayYear
Date of Referral*

MonthDayYear
Location*
Client Age*

0-21Over 21
CLIENT INFORMATION
Client Name*

First NameLast Name
Gender*

MaleFemalePrefer not to disclose
Date of Birth*

MonthDayYear
SS#
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Language*
Parent/Guardian Name*
Email*
Phone Number *
Additional Phone Number
Are you the child's parent/guardian?*

YesNo
Relationship to Child
Are you a DCFS worker?*

YesNo
Legal Guardian*

I certify that this is the legal guardian.
Type of Payment/Insurance*

MedicaidSelf-PayCommercial Insurance
Type of Payment/Insurance*

Self-PayCommercial Insurance
Commercial Insurance*
Other Insurance*
Insurance Policy Number
Insurance Member ID
Name of Insured
Date of Birth Insured

MonthDayYear
Reason(s) for Referral (Check all that apply):*

Abuse/NeglectAnxietyBehavior IssuesCommunity IssuesDepressionDifficulty CommunicatingFamily IssuesGrief (Loss)IEPInadequate ShelterLack of SupervisionLegal IssuesMedical IssuesMedication ManagementMental Health ConcernsSchool IssuesSelf-harmSubstance UseSuicidalTrouble Adjusting
Reason(s) for Counseling (Check all that apply):*

DepressionAnxietyGrief (Loss)StressImpacts of TraumaParenting SupportPost-partum DepressionRelationship ConflictMental Health ConcernsFamily IssuesSeparation, Divorce, or Blended Family AdjustmentsOther
Reason for Counseling Details or Description*
Has the child had any other services previously/currently?*

YesNo
Previous/Current Services (LA)*

Brokers of HopeCounselingCourt Appointed Special Advocate (CASA)Children’s Advocacy Center (CAC)Coordinated System of Care (CSoC)Department of Children and Family Services (DCFS)Families in Need of Services (FINS)Medication ManagementOJJ/ProbationWraparound ServicesOtherNone
Previous/Current Services (MS)*

Child Protective Services (CPS)Children’s Advocacy Center (CAC)DYS/ProbationOtherNone
Services Requested (LA)*

Any EligibleBrokers of HopeCounselingCrisis InterventionFamily Support and Youth Transition (FSYT)Functional Family Therapy (FFT)Functional Family Therapy – Child Welfare (FFT-CW)Juvenile Drug Court Treatment (Monroe Location)Medication Management (West Monroe Location)Trauma Focused-Cognitive Behavioral Therapy
Services Requested (MS)*

Any EligibleCommunity Support ServicesOutpatient CounselingPeer SupportPlay TherapyTrauma Focused-Cognitive Behavioral Therapy (TF-CBT)Eye Movement Desensitization and Reprocessing (EMDR)
Services Requested*

Any EligibleMental Health AssessmentMental Health CounselingTrauma-Focused Cognitive Behavioral Therapy (TF-CBT)Eye Movement Desensitization and Reprocessing (EMDR)Accelerated Resolution Therapy (ART)
REFERENT INFORMATION
Referent Name *
Referent Phone*
Referent Email
Referent Address

Street Address

Street Address Line 2

CityState

Zip Code
Agency *
Referent Supervisor
Supervisor Phone
Supervisor Email
Preferred Counselor/Clinician
Preferred Modality
How Did You Hear About Us?*
Should be Empty:

CLIENT INFORMATION

REFERENT INFORMATION