"*" indicates required fields

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Today’s Date

A) 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*
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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.
A9) Gender
A10) Ethnicity

B) Parent or Legal Guardian Information

Skip this section if referred individual is over the age of 18 and/or does not require a parent or legal guardian.
B1) Name
Examples: Mother, Father, Foster Parent, Aunt, Grandmother
B4 a) Address
Check and skip address if the same as referred individual.
B4b) Address – Parent or Legal Guardian

C) Emergency Contact Information

Please 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.
C1b) Name – Emergency Contact

D) Person Making the Referral

D1) Relationship to the referred person:
D2) Name – Person making the referral*

E) Requested Services

If you are unsure or do not know what services are needed select “unknown/unsure”.
E1a) Requested services for referred individual:

F) Siblings and Other Children in the Home

Please 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
F1a) Child 1 – Name
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F1d) Child 1 – Gender

F2a) Child 2 – Name
MM slash DD slash YYYY
F2d) Child 2- Gender

F3a) Child 3 – Name
MM slash DD slash YYYY
F3d) Child 3- Gender

F4a) Child 4 – Name
MM slash DD slash YYYY
F4d) Child 4 – Gender

F5a) Child 5 – Name
MM slash DD slash YYYY
F5d) Child 5 – Gender

F6a) Child 6 – Name
MM slash DD slash YYYY
F6d) Child 6 – Gender