Appointment | Family Resource & Development Center, LLC

Today's Date

Your Name:*

Email:*

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Phone:*

Referral Source:

Client Name:

Date of Birth

Concerns and Reasons for this Appointment Request

If 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

*Due to the unusually high volume of therapy requests and a long waitlist for our therapists who accept insurance, our only available therapists at this time are our "Associate-level" clinicians who cannot be paneled independently to accept insurance. We apologize for this temporary pause and we are working hard to intake new waitlisted clients as spots become available. Please check back periodically for updates regarding availability of our insurance credentialed therapists.

Anthem/Husky ID#

Please leave blank at this time as we are working our way through a waitlist of Anthem and Husky covered clients. Check back in a few weeks as we are working to open up spots for clients covered by these plans

Policy Holder Name:

Please leave blank at this time as we are working our way through a waitlist of Anthem and Husky covered clients. Check back in a few weeks as we are working to open up spots for clients covered by these plans

Policy Holder DOB

Please leave blank at this time as we are working our way through a waitlist of Anthem and Husky covered clients. Check back in a few weeks as we are working to open up spots for clients covered by these plans

Today's Date

Referral Form