Referral Form This form is to be used to make referrals or refer yourself to Still Waters Professional Counseling Services, Inc. After the referral is received you will be notified by one of our staff acknowledging receipt of the referral form and to set-up an appointment Date of Referral* MM DD YYYY Referred Individual InformationInformation pertaining to the individual being referred for services to Still Waters Professional Counseling Services, Inc.. This could also be a self referral.Name of Referred Individual* First Middle Last Suffix NicknameDate of Birth MM DD YYYY Medicaid/Insurance #Social Security # (Optional)Phone - HomePhone - MobilePhone - WorkAddress - Referred Individual's current physical living location. Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Gender Male Female Transgender Unknown Other Declined to Specify Ethnicity American Indian or Native Alaskan Asian Bi-Racial African-American (Black) Declined to Specify European Latin American / Hispanic Native Hawaiian or Other Pacific Islander Other White Declined to Specify Sexual Orientation (Optional) Heterosexual Homosexual Bisexual Other Non-Comforming Other Declined to Specify Describe the behaviors/issues/problems that are the reason for needing services:Parent or Legal Guardian InformationSkip this section if Referred Individual is over the age of 18.Name - Parent or Legal Guardian First Middle Last Suffix Relationship to the Referred IndividualEample: Mother, Father, Foster Parent, Aunt, GrandmotherPhone - HomePhone - MobilePhone - WorkCheck and skip address if the same as Referred Individual Address same as Referred Individual Address - Parent or Legal Guardian Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Emergency Contact InformationPlease indicate whom would be best to contact in the case of an emergency.Check and skip this section if the Emergency Contact is the same as the Parent or Legal Guardian Same as Parent or Legal Guardian Name - Emergency Contact First Last Phone - HomePhone - MobilePhone - WorkPerson Making the ReferralRelationship to the Referred Person Self - Skip the rest of the section if over the age of 18. Parent or Legal Guardian Other Family Member or Friend DFCS School/School Counselor Pediatrician/Physician/Doctor Department of Juvenile Justice (DJJ) Mental Health Facility Georgia Crisis Access Line Hospital NECCO (Foster System) Court Other - Organization (Please describe below.) Person Making the Referral - Name* First Last Name - Company/OrganizationPhone*Phone - MobileEmail* Requested Services for Referred PersonIf you are a self referral or referring as a family member or friend, skip this section.Requested Services - Insurance or Self-Pay ServicesIntensive Family Intervention (IFI)Community Support Intervention (CSI)Psychiatric/Medication ServicesParenting ClassAnger Management GroupSubstance Abuse GroupIndividual CounselingFamily CounselingUnknown or Other Services (Describe Below)Requested Services - (DFCS Only) - DFCS Funded ServicesHomesteadBrief InterventionPsychiatric/Medication ServicesParent AidePUP - Drug ScreensPUP - Assessments (Describe below.)Other Services - Please DescribeSiblings 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.Child 1 First Middle Last Suffix Date of Birth - Child 1 MM DD YYYY Medicaid/Insurance Number - Child 1Gender - Child 1 Male Female Transgender Unknown Other Declined to Specify Child 2 First Middle Last Suffix Date of Birth - Child 2 MM DD YYYY Child 3 First Middle Last Suffix Date of Birth - Child 3 MM DD YYYY Child 4 First Middle Last Suffix Date of Birth - Child 4 MM DD YYYY Child 5 First Middle Last Suffix Date of Birth - Child 5 MM DD YYYY Child 6 First Middle Last Suffix Date of Birth - Child 6 MM DD YYYY Visits: 428
