DSS Referral Form
Referral Information
Please fill out the information below to refer a patient for spiritual counseling. All information will be kept confidential.
Date of Referral
-
Month
-
Day
Year
Date
Type of Referral
Domestic Violence
Anger Management
Personal/Relational Growth
Does the client have reliable transportation to the Family Training Center?
Yes
No
If you answered "No", Does this Client live within 5 miles of the Training Center and/or able to find reliable transportation?
If you do not have reliable transportation or live within 5 miles of the Training Center, CFADD may not be the most suitable provider for your needs at this time.
What type of case is this? (check below)
Family Preservation Case
FCCSS Case
Foster Case
Court Involvement?
Yes
No
Referring Organization
Organization Name
Referring Professional’s Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Client Information
Client Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Preferred Contact Method
Email
Phone
Reason for Referral
Brief Description of Client's Need for Spiritual Counseling
Please provide a brief description of the reason for referral. Feel free to include any relevant emotional, spiritual, or life challenges
Consent
I, [Client], consent to being referred to Christian Families Against Destructive Decisions (CFADD) for spiritual counseling. I understand that CFADD will contact me to provide counseling services and that this information will be kept confidential.
Yes, I consent to the referral.
No, I do not consent.
Signature
Date
-
Month
-
Day
Year
Date
Referral Preferences
Preferred Counseling Type (Check all that apply)
One-on-One Counseling
Group Counseling
Type option 3
Crisis Support
Other
Preferred Method of Counseling
In-Person
Phone
Video Call
Additional Notes/Comments (Optional)
Continue
Continue
Should be Empty: