Positive Changes Counseling
Information about Person Completing Referral
Name
First Name
Last Name
Preferred Location
Please Select
Lancaster
Virtual
Mesquite
Preferred Therapist
Please Select
Tamika Johnson, LPC(Both Locations)
Dr. Fraser (FT only Lacaster)
D'Erica Davis, LPC(Both Locations)
Amy Nickerson, LCSW(Both Locations)
Sandi Johnson, LPC Associate(Both Locations)
Megan Boyd, LPC(Mesquite)
Andrea Powell, LMSW(Lancaster)
Shaniqua James, LMSW(Lancaster)
Tracy Young-Brown, LMSW(Mesquite)
Tammi Abney, LPC (Lancaster)
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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.
Format: (000) 000-0000.
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
No Cost Family Tree Counseling (with youth 6-17)
Couples
Evaluation
Form of Payment
Out of Pocket
FAMILY TREE( Dallas or Denton County Residents Only)
Optum/UHC/Oscar
CIGNA/CIGNA EAP
BCBS
AETNA
Other
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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