DFCS Referral Form

Person Being Referred Information
Services Requested*

Psychological Evaluation 54ADomestic Violence Assessment 29AParental Fitness 29CSubstance Abuse Assessment 29ETrauma Assessment 29F
DFCS Case Number:*
Client's Name:*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Is this Submission for a Child:*

YesNo
School Name
Grade:
Parent/Guardian Name

First NameLast NameRelationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Who has legal custody?
Relationship:
Who is responsible for bringing the individual to the evaluation? (Child will need to be brought by someone who is aware of their history and behaviors so they are able to complete all intake and testing paperwork)
Individual Primary Language*

EnglishSpanishOther
Reason for Referral*
Does the individual have any previous Mental Health History?*

YesNo
If yes, please provide name and dates of the psychiatric hospitalization and attach previous psychological reports or hospital summaries.
Attach the Psychological Reporting or Hospital Summaries

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What is any current Mental Health diagnosis have been reported or suspected?*
Please list any current medical health diagnosis:*
Previous criminal history*

YesNo
DOCUMENTS THAT MUST ACCOMPANY A REFERRAL:

CCFA / Family History / Social Summary

Previous / Current Mental Health Records

School Records

Court Order / Shelter Order

Criminal History / Police Reports / Victim Statements

DFCS History
File Upload

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DFCS Child/Parent Relationship Form

	Child's Name (First and Last Name	Gender	Date of Birth (Month-day- Year)	Mother/Father's Name
x
x
x
x
x
x
x
x
x
x