NEW REFERRAL FORM 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 A2) Nickname A3) Date of Birth* MM slash DD slash YYYY A4) Medicaid/Insurance #A6a) Phone - HomeA6b) Phone - MobileA6c) Phone - WorkA7) Address - Referred Individual's current physical living location. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code A8) Gender Male Female Transgender Unknown Other Declined to Specify A9) 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 A10) 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.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 C2a) Phone - HomeC2b) Phone - MobileC2c) Phone - WorkD) Person Making the ReferralD1) Relationship to the referred person: Self - Skip the rest of the section if over 18 Parent or Legal Guardian 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 D3) Company/Organization - Name D4a) Phone - OfficeD4b) Phone - MobileD5) Email E) Requested ServicesIf you are a self-referral or referring as a family member or friend, skip this section.E1a) Requested services for referred individual: 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 Bariatric Psychiatric Evaluation P*A*S*S* Unknown or 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 Middle 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 Middle 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 Middle 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 Middle 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 Middle 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 Middle Last Suffix F16) 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
