COUNSELING REFERRAL FORM

Demographic Information

Date:

Youth's Name:

D.O.B.:

Gender:
---MaleFemale

Ethnicity:
---African AmericanCaucasianHispanicBiracialAsian AmericanOther

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:

Referred by:

Parent/Guardian Information

Parent/Legal Guardian Name:

Relationship:

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.

Tell us about some of the concerns you see? (Check all that apply)

Anger ManagementAnxietyAbuse/ViolenceRunning AwaySocial SkillsDepressionInattentivenessSelf EsteemDisrespectfulJob Development SkillsHyperactiveTraumaBullyingFailing to Follow RulesPower/Control ChallengesFamily ConcernsWithdrawnEating DisorderPeer-Issues/Social SkillsSubstance AbuseGrief and LossAttachment IssuesSibling RivalrySchool-Related IssuesAdoption/Foster-care Adjustment IssuesCrisis InterventionRelationship Concerns

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Tell us about some of the strengths you see? (Check all that apply)

Curious and CreativeLove of LearningHonestKindSelf-ControlLeaderHobbies/PassionsShare Take Turns and CompromiseCopes When FrustratedLikes Community Service ProjectsEnjoys CookingLikes Talking to PeopleWorks on Difficult TasksGood ListenerExpresses Wants and NeedsGood Grades at SchoolAccepts Differences in OthersEnjoys ReadingLearn from MistakesHelp OthersSolve Puzzles or Word ProblemsEnjoys Video GamesMakes Friends and Keeps ThemHelpful at Home and Does ChoresGood Sense of HumorSings or Plays a Musical InstrumentPlays SportsFollows Rules and RoutinesMakes Good ChoicesFollow Rules and RoutinesEnjoys Drawing or DoodlingEnjoys MathDoes Not Argue with Adults

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What kind of help would you like? (Check all that apply)

AssessmentsCase ManagementChild PsychiatryBehavior SupportIndividual CounselingCrisis Residential ServicesIn-Home CounselingGroup Therapy to address above ConcernsMentoringParent Support GroupPsychoeducationIndependent Living ServicesFamily CounselingFamily Art TherapySubstance Abuse EducationRecreational TherapyDrug Prevention GroupsRelaxation TherapySkill Building/Community ActivitiesTrauma Focused CBTArt TherapyPositive Youth Development

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