Client Information
Client Name
*
Date of Birth
*
-
Month
-
Day
Year
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Gender / Gender Identity (preferred pronouns)
*
Is the client a child or an adult?
*
Child
Adult
Emergency Contact Name
Emergency Contact Phone Number
Parent/Caregiver Contact Name
Parent/Caregiver Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Caregiver Contact Email
example@example.com
Is the person mentioned above the legal guardian?
Yes
No
Legal guardian name
First Name
Last Name
Primary Language
*
Best way to contact client
*
Please Select
Phone
Email
Client Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Client Email
example@example.com
Consent to contact this number?
Yes
No
Consent to contact this email?
Yes
No
(If under 18, please confirm consent is from parent/caregiver/guardian)
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Referral Information
Reason for Referral / Presenting Problem
*
Relevant Background Information
Current Services Receiving, If Any
School / Early Childhood Program(s)
Child Welfare / CPS / DSS
Home Visiting Program(s)
Mental Health Services
Substance Use Treatment
Is client currently attending school?
*
Yes
No
Session Availability
Best Day(s)/Time(s) Client Is Available for Sessions. Client intensives are scheduled for one week, starting Mondays, with intensives occurring either 9 am – 11:45 am or 1 pm – 3:45 pm.
*
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Referrer Contact Details
Name and Title of Referrer
*
Phone Number (Referrer)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email (Referrer)
*
example@example.com
Relationship to Client
*
Counselor/Therapist
Case Manager
Other
If checked, other Relationship to Client
Is the Client/Family Aware That Referral Is Being Sent?
*
Yes
No
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