adolescence referral form Please enable JavaScript in your browser to complete this form.Referral Information:Date of Referral Source of Referral *SelfParentFacilityParent InformationParent Phone NumberFirstLastParent PhoneParent AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIs the patient aware of referral? *YesNoName of Facility and/or ProviderClient Information:Client Name *FirstLastParent/Legal Guardian Name: *(If Foster Parent or Legal Guardian, copy of Court Order required)Email *Phone *AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of BirthGenderAgeEthnicity:Is the client of Hispanic, Latina/o, or Spanish Origin YesNoUnknownRaceBlackWhiteHispanicOtherIs client employed? Yes No UnknownIs client a veteran? Yes No UnknownIs client homeless? Yes No UnknownReason For Referral:Please write a brief description of the client’s presenting problem:Were you court-ordered to seek psychiatric services? Yes No Was client previously seen by another mental health facility and/or providerYes No If yes, please indicate name of facility and/or provider:Past Diagnosis:List any known physical / medical condition(s), if any: List known medication(s), if any: Please indicate service(s) for which you are referring this individual:Outpatient Mental Health Services:Individual TherapyFamily TherapyGroup TherapyPsychiatric EvaluationDiagnostic EvaluationPsychiatric Rehabilitation Program (Adult)Psychological TestingPlease make sure to present the following documents at the time of registration and intake: Proof of Identification (Birth Certificate & Social Security Card, Driver License or State Identification Card) Proof of InsuranceBring all medications currently taken Copies of Immunization Record Most recent Physical Exam (must be within past year) Copy of last report card (if applicable) Copy of IEP or 504 plan (for students receiving special education services) If the consumer is a minor, copies of legal documents related to a minor’s status must be provided prior to services being rendered, i.e. (court orders, custody agreements, etc. Upload any documents or attachments Click or drag files to this area to upload. You can upload up to 3 files. Submit
