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
