Counseling Referral Form

Referral Information

REFERRED BY

Please provide the name of the person making the referral.

CASE NUMBER

CONTACT INFORMATION OF REFERRAL SOURCE

Client Information

CLIENT'S NAME *

Please provide the client's full name.

ADDRESS *

Please provide the client's address.

AGE *

Please provide age.

SEX *

Please select gender.

SOCIAL SECURITY

DATE OF BIRTH *

Please provide date of birth.

RACE/ETHNICITY

SCHOOL AND GRADE LEVEL

UNDER FAMILIES FIRST NETWORK SUPERVISION?

Parent/Guardian Information (If client is a minor)

PARENT/GUARDIAN NAME

DATE OF BIRTH

TELEPHONE

RELATIONSHIP TO CHILD

ADDRESS

Dependency Information (if applicable)

DCF INVESTIGATOR AND/OR CASE MANAGER

TELEPHONE

Abuse Documentation

PERPETRATOR

RELATIONSHIP TO VICTIM

DATE OF ABUSE/DISCLOSURE

AGE OF VICTIM WHEN ABUSE OCCURRED

REPORTED TO

TYPE OF ABUSE

BRIEF DESCRIPTION OF ABUSE

Reason for Referral

REASON FOR COUNSELING REFERRAL *

Please provide the reason for this referral.

PREVIOUS COUNSELING HISTORY

URGENCY LEVEL

PREFERRED CONTACT METHOD

Additional Information

ADDITIONAL COMMENTS OR CONCERNS

DATE OF REFERRAL *

Please provide the date of referral.

REFERRAL SOURCE SIGNATURE *

Please provide your electronic signature.

Note: All information provided will be kept confidential and used only for the purpose of providing appropriate counseling services.

Gulf Coast Kid's House