* = Required Information
REFERRAL FOR SERVICES
Date of Referral
*
Residential County
*
Client's Name
*
Date of Birth
*
Address
*
Social Security #
Phone #
*
Race
Gender
Male
Female
Medicaid
Yes
No
Medicaid I.D.#
Other Funding Source
Referral Source Name
Phone #
Referral Source Agency
What services are currently being provided to this client?
Check all that apply
Hospitalized within the year
In a detention, prison, or jail within the last year
Police have been called to the home due to the client’s behavior within the last 12 months
Convicted of two or more serious misdemeanors within the past 12 months
Currently in DCP&P custody
Child is involved with:
DCP&P
Juvenile Justice
CMO/Community Organizations
Check all that apply:
Services you wish to receive:
1. IIC/BA Services:
IIC Clinical
IIC Master
BA
BPS Need Assessment
Substance Abuse Eva
2. DDD Support Coordination Services
3. Mental Health Services
OP
IOP
4. Group Therapy
Name
Day & Time
5. Addiction Treatment Services
OP
IOP
Partial Care
6. Sexual Offender Treatment Services
7. EAP Services
8. DWI Services
9. Sexual Abuse and Trauma Victims Services
10. Domestic Violence Services
11. HIV and AIDS Services
12. Court Mandated Parenting Classes Services
13. Court Mandated Anger Management Classes Services
14. Supportive Housing Services
15. Veteran Services
16. Family Therapy/Couple Therapy
17. Psychiatric Evaluation and Psychological Testing
Parent/Guardian’s Signature (if applicable)
Additional Problem Areas/Needs and or Comments
Referral Source Signature
*
Date
*
Submit