Behavioral Health Referral Form
FamilyCare Counseling Solutions, LLC
Information about Person Completing Referral
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Desired Goal/Results:
Individual Information
Is Individual aware of this Referral?
Yes
No
Name
First Name
Last Name
Name of Parent/Guardian (if applicable)
First and Last Name
Date of Birth
-
Month
-
Day
Year
Social Security Number
Individual Gender
Male
Female
Other
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Coverage
What type of primary insurance coverage do you have?
Please Select
Medicaid
Commerical/Private
Dual Coverage (Commerical/Medicaid)
Self-Pay
Provide the information below:
Provide the information below:
Select a photo method for your Insurance Card
File Upload
Take Photo Using my Rear Facing Camera
Bring to first appointment
Upload Copy of Insurance Card (Front & Back)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Take Photo of Insurance Card Using my Rear Facing Camera
Type of Services Needed
Adult Outpatient Services
Reunification Services
Child/Adolescent Outpatient Services
Drug/Alcohol Services
School-Based Services
Employer/School Name (if applicable)
Parent/Guardian Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Specify Service:
Individual Therapy (Mental Health ONLY)
Group Therapy (Mental Health ONLY)
Family Counseling (Mental Health ONLY)
Reunification Family Therapy Program
Intensive Outpatient Program (IOP) (Substance Use)
Aftercare Program (AC) (Substance Use)
Targeted Case Management (TCM)
Peer Supports
Other
Reason for Referral/Presenting Problems
Current Medications
Select all applicable challenges below for the Individual referred (check all that apply)
Ability to avoid dangers/hazards
Anger
Anxiety
Community Linkage of Services
Daily living skills
Depression
Grief
Housing
Hygiene
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Maintaining personal affairs
Medication Education
Nutritional
Phobia/s
PRTF/Hospital Discharge
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Sustainable employment
Trauma
Truancy
Whole Health/Wellness
Youth to Young Adult Transition
Other
Additional Notes/Comments:
Submit
Should be Empty: