REFERRAL (English):
LCDA Bilingual Treatment Program
Who referred you to LCDA?
Myself
The Court
DHS
Other
Please provide their name and phone number.
Please explain why they have referred you.
What brings you here today?
Is this referral for you or your child?
For me
For my child
Do you need parenting classes?
Yes
No
Does your child have problems at school?
Yes
No
Does your child have problems outside of school?
Yes
No
Please explain what the problem is.
What language does the child prefer to speak?
English
Spanish
What language does the parent prefer?
English
Spanish
Does your partner mistreat you? For example, says ugly things to you or hits you.
Yes
No
Not me, but my child.
Has an attorney and/or the Court sent you because you have had problems with your partner?
Yes
No
Do you (or your child) have problems with drugs or alcohol?
Yes
No
Do you (or your child) need a Drug Test?
Yes
No
Do you (or your child) feel depressed, sad, or stressed?
Yes
No
Do you (or your child) need Mental Health therapy?
Yes
No
Please explain why.
Are you receiving any other services in this or another Agency?
Yes
No
Please write down the name of your program / agency.
Is there anything else you want us to know?
Solicited Program
Individual therapy
Couples therapy
Family therapy
Child trauma
Child mental health
Parenting Classes
Hombres de Paz/ BIP
Proyecto Cambio/ DV
Substance abuse
Anger management
Referred Client Information
Please use the information of the person who will be receiving services at the agency.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Gender
Male
Female
Non-binary
Preferred Language
English
Spanish
Name of Parent or Tutor
First Name
Last Name
Phone Number
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
Medicaid/Soonercare Number
Submit
Should be Empty: