Mariposa Referral Form

MARIPOSA REFERRAL FORM
Date of Referral*

MonthDayYear
Date
Referring Program/Agency*
Other Agency
Referring Staff/Title*
Referring Staff Email
example@example.com
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Primary Language*
Other Language
(Please specify)
Address/Location*
Mobile Phone Number*
Email*
example@example.com
Gender*
Another Gender
(Please specify)
Relationship Status*
Race/Ethnicity*
Other Race/Ethnicity
You are welcome to provide specifics about your race or ethnicity to better serve you.
New or Returning Client*

NewReturning
Date Last Seen

MonthDayYear
Date
Type of Counseling*
Prior Psych. Hospitalizations?*

YesNo
Preference, Female or Male counselor (preferences are considered and not guaranteed)*

FemaleMaleNo preference
Location Preference*

In-person OrangeIn-person San Juan CapistranoIn-person fieldTelehealth
Client Self-Report or Presenting Issues:*
Are you currently receiving counseling services from a community provider?*

YesNo
Days of the week/times are you available for counseling services? *
Do you agree to receive text messages and emails for appointment reminders, events, and other information? (Mariposa will not sell or disclose contact information.) *
Attestation of Client Consent for Third-Party Referral

I, the undersigned client, authorize the disclosure of the information above to Mariposa Women and Family Center. I agree this authorization shall be valid from the date I sign until discharge from services, or if I request in writing that the authorization be withdrawn.
Client Name*
Client Signature*

Clear
Date (Client)*

MonthDayYear
Date
Provider Name*
Provider Signature*

Clear
Date (Provider)*

MonthDayYear
Date
SH DECEMBER 2024
Should be Empty:

MARIPOSA REFERRAL FORM