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Community Therapeutic Services Referral Form
Thank you for your referral, we appreciate your trust in Community Therapeutic Services. Please complete the referral form below and our team will contact the individual shortly to introduce ourselves and provide next steps. Thank you for helping us make a positive impact on the lives of individuals and families in our community.
Name of Person Making Referral
*
Referral Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referral Source
*
Physician
Hospital
Social Worker
School
Case Manager
Family or Friend
Community Organization
Walk-In
Other
Client Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Social Security Number
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Marital Status
*
Please Select
Single
Married
Widowed
Divorced
Separated
Other
N/A
Email
*
example@example.com
Preferred Method of Contact
*
Phone Call
Text Message
Email
Gender
*
Please Select
Male
Female
Race
*
Please Select
Black or African American
Hispanic
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
White
Middle Eastern or North African
Multiracial
Other
Parent/Guardian Name
*
First Name
Last Name
Relationship to Client
*
Case Manager
Please enter a valid phone number.
Format: (000) 000-0000.
School/Social Worker
Please enter a valid phone number.
Format: (000) 000-0000.
Psychiatrist
Please enter a valid phone number.
Format: (000) 000-0000.
Therapist
Please enter a valid phone number.
Format: (000) 000-0000.
Please Check All that Apply
*
Confused Thinking, Delusions or Hallucinations
Depression, Sadness or Irritability
Defiance of Authority, Truancy, Theft and/or Vandalism
Excessive Worry or Anxiety (i.e. Refusing to go to Bed or School)
Fear of Weight Gain
Excessive Fears, Worries and Anxieties, Suicidal Thoughts
Poor Appetite
Social Withdrawal
Disobedience or Aggression
Feelings of Not Coping with Daily Problems
Decreased Social Skills
Excessive Complaints of Physical Ailments
Changes in School Performance
Poor Grades
Feelings of Extreme Highs and Lows
Hyperactivity
Negative Mood
Nightmares
Thoughts of Death
Changes in Eating or Sleeping Habits
Temper Tantrums
Outbursts of Anger
Reason for Referral
*
Insurance Information
*
Humana
Louisiana Healthcare Connections
Healthy Blue
AETNA
Unknown
Referral Identification
*
Standard
CRISIS
Consent and Authorization
I confirm that I am authorized to submit this referral and that the information provided may be used by Community Therapeutic Services to contact the client or their parent/guardian.
*
I Agree
I understand that this form is not for emergency assistance and that additional consent may be required before services or further information sharing can occur
*
I Agree
Submit
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