SAFE PLACE COUNSELING & CONSULTING LLC

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
(1) REFERRAL

PERSON COMPLETING THIS FORM
YOUR NAME*
REFERRAL AGENCY NAME/INSTITUTION (IF ANY):
YOUR PHONE NUMBER:*
YOUR EMAIL:*
example@example.com
WHO IS BEING REFERRED FOR SERVICES
IF SOMEONE ELSE, WHAT IS YOUR RELATIONSHIP TO THE PERSON (CLIENT) BEING REFERRED FOR SERVICES?
(2) CLIENT INFORMATION

PERSON BEING REFERRED FOR SERVICES
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
CLIENT DOB*
CLIENT PREFFERED LANGUAGE
DOES CLIENT NEED AN INTERPRETER?
DOES CLIENT HAVE INSURANCE?*
IF YES, NAME OF INSURANCE
IF YES, POLICY # OR MEDICAID #
NAME OF PARENT/GUARDIAN/LAR (IF APPLICABLE)
PARENT/GUARDIAN/LAR PHONE NUMBER
Please enter a valid phone number.
(3) CLIENT MEDICAL HISTORY
PRESENTING PROBLEM OR DIAGNOSIS*
BRIEFLY EXPLAIN THE CLIENT'S CURRENT PROBLEM OR NEED AND DESCRIBE ANY PERTINENT PAST INFORMATION WE SHOULD KNOW.
IS THE CLIENT CURRENTLY ENROLLED WITH ANOTHER MENTAL HEALTH PROVIDER*

YesNo
IF YES, PLEASE PROVIDE FACILITY NAME AND LAST DATE SEEN
IS THE CLIENT CURRENTLY TAKING MEDICATION FOR MENTAL HEALTH ISSUES

YesNo
HOW DID YOU HEAR ABOUT US*
IF REFERRAL, WHAT IS HIS/HER NAME
ACKNOWLEDGEMENT

I do understand that this form is only a referral to make or 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 and 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.
Signature of Referral (Person completing this form)

Clear
Visit us at www.safeplacecounseling.org
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REFERRAL FORM

(1) REFERRAL

(2) CLIENT INFORMATION

(3) CLIENT MEDICAL HISTORY