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):
WHAT IS YOUR RELATIONSHIP TO THE PERSON (CLIENT) BEING REFERRED FOR SERVICES

Other
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.Format: (000) 000-0000.
CLIENT EMAIL
example@example.com
DOB
AGE
GRADE (If Applicable)
GENDER
RACE
SS# (Optional)
Does the client have medical insurance (i.e. Medicaid, Blue Cross Blue Shield, United Healthcare, Aetna, Molina, etc.)
PARENT/GUARDIAN NAME (If Applicable)
PARENT/GUARDIAN Email
example@example.com
PARENT/GUARDIAN PHONE
Format: (000) 000-0000.
ALTERNATE NUMBER
SCHOOL/EMPLOYER (If Applicable)
PREFFERED LANGUAGE
NEED INTERPRETER: YES / NO
PRESENTING ISSUE(S)
IS THE RECIPIENT CURRENTLY ENROLLED WITH ANOTHER MENTAL HEALTH PROVIDER
IF YES, PLEASE PROVIDE FACILITY NAME AND LAST DATE SEEN
IS THE RECIPIENT CURRENTLY TAKING MEDICATION FOR MENTAL HEALTH ISSUES
PRIMARY CARE PHYSICIAN
PHONE#
Format: (000) 000-0000.
DATE OF LAST HOSPITALIZATION (IF APPLICABLE)

MonthDayYear
Date
REFFERED BY (YOUR NAME)
YOUR 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.
Referral Signature
Date

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

REFERRAL FORM

REFERRAL SOURCE

CLIENT PERSONAL INFORMATION

NEED INTERPRETER: YES / NO