Positive Changes Counseling
Information about Person Completing Referral
Name
First Name
Last Name
Preferred Location
Please Select
Desoto
Virtual
Mesquite
Preferred Therapist
Please Select
Tamika Johnson, LPC
D'Erica Davis, LPC
Amy Nickerson, LCSW
Sandi Johnson, LPC Associate
Megan Boyd, LPC
Andrea Powell, LMSW
Shaniqua James, LMSW
Tracy Young-Brown, LMSW
Tammi Abney, LPC
Email
example@example.com
Phone Number
Please enter a valid phone number.
Individual Information
Name of Individual Being Referred
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Parent/Guardian/Foster Parent /CPS Case Worker's Name
First Name
Last Name
Relationship
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Is the Individual aware of this Referral?
Yes
No
Form of Payment
Please Select
BCBS
Aetna
Optum/United Health/Oscar
Cigna
Superior Medicaid
Out-of-Pocket
Type of Services Needed
Adult
Child
Adolescent
Family Counseling
Couples
Evaluation
Program Needed
Mental Health
FAMILY TREE( Dallas County Residents Only)
Child/Adolescent Group Services
CANS ASSESSMENT
Drug Testing
Case Management for CPW
Individual Gender
Male
Female
Other
Individual Primary Language
English
Spanish
Other
Select all applicable challenges below for the Individual referred (check all that apply)
Anger
Anxiety
Community Linkage of Services
Depression
Grief
Juvenile Justice/Court Involved
Nutritional
Phobia/s
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Trauma
Truancy
Other
Submit
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