Safe Place Referral Form

REFERRAL FORM
COMPLETE THE FORM BELOW FOR YOURSELF OR ANYONE ELSE YOU BELIEVE WILL BENEFIT FROM THE SERVICES WE PROVIDE. WE WILL MAKE CONTACT TO ARRANGE AN INTERVIEW AND DETERMINE ELIGIBILITY FOR SERVICES. IF YOU HAVE ANY QUESTIONS OR CONCERNS, PLEASE CALL US AT (832) 739-9558 OR BY EMAIL AT INFO@SAFEPLACECOUNSELING.ORG.
DATE OF REFERRAL

MonthDayYear
Date
REFERRAL SOURCE
YOUR NAME (PERSON MAKING REFERRAL)*
REFERRAL AGENCY NAME/INSTITUTION (IF ANY):
YOUR PHONE NUMBER:*
WHAT IS YOUR RELATIONSHIP TO THE PERSON (CLIENT) BEING REFERRED FOR SERVICES
CLIENT PERSONAL INFORMATION
CLIENT NAME*
CLIENT ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CLIENT PHONE NUMBER*
Please enter a valid phone number.
CLIENT EMAIL*
example@example.com
DOB
AGE
GRADE (If Applicable)
GENDER
RACE
SS# (Optional)
MEDICAID #
INSURANCE PROVIDER*
If unknown please enter N/A
ADDRESS
PHONE*
ALTERNATE NUMBER
Email*
example@example.com
PARENT/GUARDIAN NAME (If Applicable)
SCHOOL/EMPLOYER (If Applicable)
PREFFERED LANGUAGE
NEED INTERPRETER: YES / NO
PRESENTING ISSUE(S)
PRIMARY CARE PSYSICIAN
PHONE#
DATE OF LAST HOSPITALIZATION

MonthDayYear
Date
IS THE RECIPIENT CURRENTLY ENROLLED WITH ANOTHER MENTAL HEALTH PROVIDER

YesNo
IF YES, PLEASE PROVIDE FACILITY NAME AND LAST DATE SEEN
ARE THEY CURRENTLY TAKING MEDICATION FOR MENTAL HEALTH ISSUES

YesNo
REFFERED BY
CONTACT NUMBER
I do understand that this form is only a referral to receive services from Safe Place Counseling & Consulting LLC and it does not guarantee enrollment into the program. Safe Place does not provide any monetary compensation for client enrollment into services. My signature on this form is an attestation that I did not receive any compensation from Safe Place Counseling & Consulting LLC and its affiliates to enroll in services.
Client Signature

Clear
Date

MonthDayYear
Date
Visit us www.safeplacecounseling.org
Should be Empty:

REFERRAL FORM

REFERRAL SOURCE

CLIENT PERSONAL INFORMATION

NEED INTERPRETER: YES / NO