* Required Information
Date of Referral:
*
Consumer's Name:
*
Date of Birth:
*
Address:
*
Social Security Number:
Phone Number:
*
Gender:
Male
Female
Insurance Coverage:
Yes
No
Primary Insurance Name/ID Number:
Secondary Insurance Name/ID Number:
Referral Source Name:
Phone Number:
Referral Source Agency:
What services are currently being provided to this consumer?
Check all that apply:
Hospitalized within the year
In a detention, prison, or jail within the last year
Police have been called to the home due to the client’s behavior within the last 12 months
Convicted of two or more serious misdemeanors within the past 12 months
DSS substantiated report within the last 12 months
Currently in DSS custody
Client is involved with:
DSS
Criminal Justice System
DPI/Schools System
LME
Health Department
Community Organizations
Court System
Services you wish to receive:
Individual Therapy (Mental Health, Behavioral Health, & Substance Abuse)
Group Therapy (Mental Health, Behavioral Health, & Substance Abuse)
Family Therapy (Mental Health, Behavioral Health, & Substance Abuse)
Sexual Offender Treatment Services
Is the parent/legally responsible party aware of this referral?
Yes
No
Consumer/Parent/Guardian’s Signature (if available):
Additional Problem Areas/Needs and or Comments:
Referral Source Signature: