Referral Form Today's Date MM slash DD slash YYYY Your Name:* Email:* Check here to receive email updates Phone:*Referral Source: Client Name: Date of Birth MM slash DD slash YYYY Concerns and Reasons for this Appointment RequestIf currently in school, please note the school district and current grade: Is the client transitioning from a higher level of care (ie. inpatient or partial hospital/intensive outpatient program)? No Yes ***(please note that we will need to speak with the referring provider in order to determine the current treatment needs before scheduling an initial appointment.) Parent/Guardian Relationship Status: Married Separated Divorced Single N/A (For adults seeking treatment) If separated or divorced, please identify degree of current conflict with other parent: None Low Medium High Explanation of "degree of current conflict" with other parent: Is the other parent in agreement with this request for the child's therapy? (unless a custody agreement communicates otherwise, our agency requires the consent of both parents for therapy to begin) Yes No N/A (instances where parents are married or potential client is an adult) Does the referred client struggle with any aggression toward him/herself or others? No Yes If aggression toward self or others exists, please explain or share with our intake specialist when you are contacted:Any current or past substance abuse? (types of substances used, was treatment suggested or received?)Type of Therapy Requested Individual Therapy Family Therapy Group Therapy Parenting/Support Group Please identify a therapist you are hoping to work with. If that therapist is not available, we will offer a therapist who meets your needs. Would you like to receive periodic updates about FRDC groups, resources, etc? (all emails are sent confidentially) Yes No Payment Source: Self Pay Anthem BC/BS Husky Anthem/Husky ID# Policy Holder Name: Policy Holder DOB MM slash DD slash YYYY Today's Date MM slash DD slash YYYY
