CHILDREN TREATMENT SERVICES REFERRAL FORM

Demographic Information

Date:

Client Name:

D.O.B.:

DCN Number:

Gender:
---MaleFemale

Ethnicity:
---African AmericanCaucasianHispanicOther

Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Work Phone:

Email Address:

OK to leave messages? (Check all that apply)

HomeCellText MsgEmailAll

School:

Grade:

Case Worker Name:

Case Number:

Case Worker Office Address:

Parent Information

Parent/Legal Guardian Name:

Relationship:

Parent/Legal Guardian Name:

Relationship:

PLEASE NOTE: Only those who are legally authorized to make decisions about medical treatment for this minor child may consent to services.

Description of Current Problem (Check all that apply)

Anger ManagementAnxietyAbuse/ViolenceSleeping ProblemsDepressionInattentivenessSelf EsteemChronic Pain/IllnessHyperactiveTraumaBullyingPower/Control ChallengesFamily ConcernsWithdrawnEating DisorderPeer Issues/Social SkillsSubstance AbuseGrief/LossAttachment IssuesSibling RivalrySchool-Related IssuesAdoption/Foster-care Adjustment IssuesCrisis InterventionRelationship Concerns

Medications:

Diagnosis:

Additional information (Please include strategies used at home/or at school):

Services Requested (Check all that apply)

Assessment (LCSW/LPC)Family Centered ConsultationSubstance Abuse AssessmentGroup TherapyAssessment in HomeFamily Centered MeetingSubstance Individual CounselingIndividual TherapyCrisis InterventionParent Education and Training ProgramSubstance Abuse Group CounselingFamily TherapyRespite CareSubstance Abuse Group EducationDrug TestingSpecial Delivery CoordinationFamily Therapy

Other Services: