Referral Out Form Today's Date MM slash DD slash YYYY Individual Being Referred for Services:Name - Individual Being Referred for Services First Middle Last Suffix Status Individual is of legal age of consent Under-age individual Individual is under the the care of a custodial parent or legal guardian Date of Birth MM slash DD slash YYYY Medicaid # Gender Male Female Transgender Unknown Other Ethnicity Address Street Address City State / Province / Region ZIP / Postal Code Phone 1Phone 2School Highest Grade Completed Custodial Parent/Legal Guardian Information:Name - Custodial Parent/Legal Guardian First Last Relationship to Referred Address Street Address City State / Province / Region ZIP / Postal Code Phone 1Phone 2Individuals's DiagnosisAxis 1 Axis 2 Axis 3 Axis 4 Axis 5 Programs/Services Currently Being Rendered:Program/Services Currently Being RenderedCheck all that apply. Medication Management Family Counseling Group Counseling Individual Counseling (IND) Community Support Individual (CSI) Intensive Family Intervention (IFI) Referred By:Still Waters Professional Counseling Services, Inc. 3711 Executive Center Dr. Augusta, GA 30907 706-955-9224Name - Person Making the Referal First Last Title - Referred By Phone - Referred ByFax - Referred ByEmail - Referred By Company Being Referred To:Company Name Name - Referred To First Last Title - Referred To Address - Referred To Street Address City State / Province / Region ZIP / Postal Code Phone 1 - Referred ToPhone 2 - Referred ToFax - Referred ToEmail - Referred To Reason for Referral:SymptomsSkill DeficitResource NeedsProgram/Services Being Referred For:Program/Services Currently Being Referred ForCheck all that apply. Medication Management Family Counseling Group Counseling Psychological Evaluation Individual Counseling (IND) Community Support Individual (CSI) Intensive Family Intervention (IFI) Δ
