Counseling Referral Form
Date of Referral
Referral Name/Agency/Phone#
Case Manager Name
Client Name , Race, Gender, Age
Address
Presenting Concern
Mental Health
Substance Abuse
Co-Occurring Disorder
Court Ordered Eval
Parent-Guardian Address
Parent-Guardian Phone
Insurance Type
Primary Service
Indiv- Youth Only
Family
Parent Enrichment
Placement Stabilization
Adult- MH
Adult- SA
Evaluation
Barriers to Treatment
Hx failed treatment
Transportation
Family Support
Placement Stability
No Barriers Identified
Language
Comments