Halo Healing Center – Client Referral Form
CLIENT INFORMATION
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
SSN
*
Race
*
American Indian/Alaskan Native
Asian
Black/African American
Hispanic/Latino
Middle Eastern
Native Hawaiian /Pacific Islander
White
Gender
*
Male
Female
Nonbinary
prefer not to say
Marital Status
*
single
married
separated
divorced
widowed
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Spanish Speaking Only?
*
Yes
No
Requested Services
Check all that apply. If unsure, select “Assessment for Group Placement.”
*
Assessment for Group Placement
Anger Management
B.R.E.A.K. F.R.E.E. (Domestic Violence)
Shoplifting Prevention
STOP Program (Solicitation Intervention AKA "John School")
DUI / DWI Evaluation
Substance Use Screening
Substance Use Psychoeducation Groups
Individual Counseling
Family Counseling
Parenting Classes
Healthy Relationships Course
Life Skills & Independent Living Groups
Decision-Making & Impulse Control
Truancy / School Refusal Support
Mental Health Evaluation
Other
Referring Party Info
Referring Name
*
Agency/Organization
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Comments or Notes
Upload Supporting Documents (if applicable)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Consent & Release
“I authorize Halo Healing Center to share relevant information with the referring entity listed below. This consent is valid for one year from today’s date unless revoked earlier.”
*
Yes
No
Client Signature: Your digital signature will serve as acknowledgment and consent.
*
Date
*
-
Month
-
Day
Year
Date
Continue
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