Referral form

Turner Mental Health Counseling, Inc The Change is Real www.TurnerMentalHealth.com
Name of referring agency/practice/ worker
Date of referral

MonthDayYear
Date
I. REFERRAL SOURCE INFORMATION
Referred By: Agency/Organization: Phone Number
Referred By
AgencyOrganization
Email
example@example.com
Full Name
Preferred Name
DOB
Gender Identity
Age
Clients Phone Number
Address
Email
example@example.com
Pronouns
Preferred Contact Method: Emergency Contact Name & Relationship: Emergency Contact Phone
Preferred Contact Method
Emergency Contact Name Relationship
Brief Description of Reason for Referral
Reasons for a referral

Therapy/counselingCase managementPeer supportOther
IV. PRESENTING CONCERNS (Check all that apply)

Mental healthEmployment/educational supportSocial isolationMedical concernsSubstance useLegal involvementHousing insecurityBenefit assistanceTrauma historyOther
V. Service requested.

Individual counseling/therapyFamily counseling/therapyGroupTrauma informed
Current Therapist
Case management services

Resource navigationBenefits such as SSI, MedicaidHousing needsTransportation needs for medical appointmentsEmployment/educationLegal supportOther
Peer support

Recovery coachingMentorshipEmotional supportCommunity connectionsGroup support
2. Case Management Resource Navigation

Employment/Education Legal Support

VI. ADDITIONAL INFORMATION (Optional)

Diagnosis (if known): Medications (if any): Current Supports/Services: Barriers to Engagement:
Medications if any
Diagnosis if known
Barriers to Engagement
Current Supports Services
I confirm that the client has given consent to be contacted.
VII. Consent to Contact.

I confirm that the client has given consent to be contacted.
Signature of Referrer

Clear
Date

MonthDayYear
Date
Should be Empty: