NEW REFERRAL FORM "*" indicates required fields Date of Referral MM slash DD slash YYYY Today’s DateA) Individual Being Referred:Information pertaining to the individual being referred for services to Still waters Professional Counseling Services, Inc. This could also be a self referral.A1) Name of Referred Individual* First Last Suffix A2) Nickname A3) Date of Birth* MM slash DD slash YYYY A4) Medicaid/Insurance #A6a) Phone – HomeA6b) Phone – MobileA6c) Phone – WorkA7) Email Please list best email to send information, notifications, and/or links for Telehealth services if applicable. NOTE: INPUT PARENT OR GUARDIAN’S EMAIL IF REFERRAL IS A MINOR!A8) Address – Referred Individual's current physical living location. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code A9) Gender Male Female Transgender Unknown Other Declined to Specify A10) Ethnicity American Indian Asian Bi-Racial African-American (Black) Declined to Specify European Latin American / Hispanic Native American or Other Pacific Islander Other White Unknown A11) Describe the behaviors/issues/problems that are the reason for needing services:B) Parent or Legal Guardian InformationSkip this section if referred individual is over the age of 18 and/or does not require a parent or legal guardian.B1) Name First Last Suffix B2) Relationship to the individual being referred: Examples: Mother, Father, Foster Parent, Aunt, GrandmotherB3a) Phone – HomeB3b) Phone – MobileB3c) Phone – WorkB4 a) Address Address same as referred individual Check and skip address if the same as referred individual.B4b) Address – Parent or Legal Guardian Street Address Address Line 2 City State / Province / Region ZIP / Postal Code C) Emergency Contact InformationPlease indicate whom would be best to contact in the case of an emergency.C1a) Check and skip this section if Emergency Contact is the same as the parent or guardian. Same as Parent or Guardian C1b) Name – Emergency Contact First Last Suffix C2) Phone – BestD) Person Making the ReferralD1) Relationship to the referred person: Self – Skip the rest of the section if over 18 Parent or Legal Guardian Still Waters Internal Other Family Member or Friend DFCS School/School Counselor Pediatrician/Physician/Doctor Dept. of Juvenile Justice (DJJ) Mental Health Facility Georgia Crisis Access Line Hospital NECCO (Foster System) Court Other D2) Name – Person making the referral* First Last Suffix D3) Company/Organization – Name D4a) Phone – OfficeD4b) Phone – MobileD4c) FaxD5) Email E) Requested ServicesIf you are unsure or do not know what services are needed select “unknown/unsure”.E1a) Requested services for referred individual: Bariatric Psychiatric Evaluation Unknown/Unsure Intensive Family Intervention (IFI) Community Support Intervention (CSI) Psychiatric/Medication Services Parenting Class Anger Management Group Substance Abuse Group Individual Counseling Family Counseling Christian Counseling P*A*S*S* FVIP (Family Violence Intervention Program) Other (Describe below.) E1b) Other Services description:F) Siblings and Other Children in the HomePlease list all children living in the home of the referred individual, particularly if they are also in need of behavioral health services.F*) Check those that apply Information on siblings or other children unknown at this time Other children in the home may need services F1a) Child 1 – Name First Last Suffix F1b) Child 1 – Date of Birth MM slash DD slash YYYY F1c) Child 1 – Medicaid/Insurance #F1d) Child 1 – Gender Male Female Transgender Unknown Other Declined to Specify F2a) Child 2 – Name First Last Suffix F2b) Child 2 – Date of Birth MM slash DD slash YYYY F2c) Child 2 – Medicaid/Insurance #F2d) Child 2- Gender Male Female Transgender Unknown Other Declined to Specify F3a) Child 3 – Name First Last Suffix F3b) Child 3 – Date of Birth MM slash DD slash YYYY F3c) Child 3 – Medicaid/Insurance #F3d) Child 3- Gender Male Female Transgender Unknown Other Declined to Specify F4a) Child 4 – Name First Last Suffix F4b) Child 4 – Date of Birth MM slash DD slash YYYY F4c) Child 4 – Medicaid/Insurance #F4d) Child 4 – Gender Male Female Transgender Unknown Other Declined to Specify F5a) Child 5 – Name First Last Suffix F5b) Child 5 – Date of Birth MM slash DD slash YYYY F5c) Child 5 – Medicaid/Insurance #F5d) Child 5 – Gender Male Female Transgender Unknown Other Declined to Specify F6a) Child 6 – Name First Last Suffix F6b) Child 6 – Date of Birth MM slash DD slash YYYY F6c) Child 6 – Medicaid/Insurance #F6d) Child 6 – Gender Male Female Transgender Unknown Other Declined to Specify Additional Notes Δ
