GTS REFERRAL FORM
Goshen Therapeutic Services
230 Marietta HWY Canton, GA 30114
Referrals Line: 770-789-3797 Email:
referrals@goshenvalley.org
Thank you for completing the referral form in its entirety. The more complete the form, the quicker we can begin services for you. Thank you for selecting and trusting us with your care.
Referral Date:
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Month
-
Day
Year
Date
Referring Party Information:
Agency (County):
Name:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Do you have insurance?
*
Yes
No
Insurance Company:
*
Member ID:
*
Insurance Policy Holder
*
Yes
No
*Please provide a copy of your Insurance Card: Front and Back
*
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Client Information:
Name:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County:
*
Phone Number:
*
Format: (000) 000-0000.
Email:
*
example@example.com
DOB:
*
-
Month
-
Day
Year
Date
Age:
*
Race/ Ethnicity:
*
Gender:
*
Male
Female
Parent/Guardian Name (If Applicable):
Name:
DOB:
-
Month
-
Day
Year
Date
Race/ Ethnicity:
Phone Number:
Format: (000) 000-0000.
Address:
Email:
example@example.com
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Presenting Concerns:
*
Services Requested (select all that apply)
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Behavioral Health Assessment
Psychological Assessment
PUP Assessment (Domestic Violence, Trauma, Substance Abuse, Parental Fitness)
Individual Counseling
Substance Abuse Counseling
Couples Counseling
Family Counseling
Behavioral Aide / Community Support Specialist
Parent Aide / Family Training
Peer Support Specialist
Supervised Visitations
Transportation
Group Services
Case Management
Are any of these services court-ordered? If yes, list which one(s) below:
Frequency of Services Requested
*
Session Type Availability:
*
Virtual
In-Person
Preferred Days:
*
Preferred Time:
*
Morning
Afternoon
Evening
Preferred Clinician:
Does the client or family have any past (last 5 years) or current DFCS involvement?
*
Yes
No
If current, what's the status of the case?
Is there a risk of removal or disruption of the family unit?
*
Who is the child living with?
*
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Mental Health Pre-Screening Form (best if completed by client)
This pre-screening form is designed to help identify mental health needs across all ages. Responses are confidential and used solely for assessments purposes.
Section 1: Presenting Concerns / Current Symptoms
Check all that apply:
*
Anxiety, excessive worry, feeling on edge
Panic attacks
Sadness or depression
Anger or irritability
Relationship or family conflict
Avoiding people or situations
School or work difficulties
Sleep problems or changes in sleep patterns
Loss or grief
Trauma or abuse
Attention or focus problems
Substance use concerns
Changes in appetite
Low self-esteem
Frequent mood swings
Thoughts of self-harm or suicide
Aggressive or violent thoughts
Other
Section 2: Mental Health History
Have you ever been diagnosed with a mental health condition? If yes, please list:
*
Have you ever received counseling or therapy before?
*
Yes
No
Have you ever been hospitalized for mental health reasons?
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Yes
No
Are you currently taking any psychiatric medications? If yes, please list:
*
Section 3: Risk Assessment
In the past two weeks, have you had thoughts of harming yourself?
*
Yes
No
Have you ever attempted suicide?
*
Yes
No
Do you have thoughts of harming others?
*
Yes
No
If yes to any of the above, please describe:
*
Submit
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