Safe Place Referral Form

SAFE PLACE COUNSELING & CONSULTING, LLC

11767 KATY FREEWAY, SUITE 1130

HOUSTON, TEXAS 77079

PH. 832-831-6178 FAX. 346-44-6549

WWW.SAFEPLACECOUNSELING.ORG

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 DETERMINE ELIGIBILITY FOR SERVICES AND SCHEDULE AN INTERVIEW ASSESSMENT. IF YOU HAVE ANY QUESTIONS OR CONCERNS, PLEASE CALL US AT OR BY EMAIL AT INFO@SAFEPLACECOUNSELING.ORG.
REFFERAL SOURCE
REFERRED BY

Other
COMPANY/AGENCY NAME
YOUR NAME
YOUR CONTACT NUMBER
YOUR EMAIL:
example@example.com
CLIENT PERSONAL INFORMATION
What is the age of the client being referred:
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
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
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
ACKNOWLEDGEMENT
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 refer myself and/or others to enroll in services.
Referral Signature
Date

MonthDayYear
Date
Should be Empty:

REFFERAL SOURCE

CLIENT PERSONAL INFORMATION

NEED INTERPRETER: YES / NO

ACKNOWLEDGEMENT