CONTACT: R. Christian, M.Ed: Executive Director

200 Elm Street, Conway SC, 29526

Office Phone: (843) 488-1615 Cell Phone: (843) 359-7538

E-mail:

REFERRAL FORM (4)

DIRECTIONS: Click exactly on the gray text box to complete the information, submit to director & call if the case requires immediate contact. Please include support documents such as evals, med info etc relevant to referral needs.

Date of Referral:

FAMILY DEMOGRAPHICS:

Referring Worker: / Phone: / e-mail:
Client;
Medicaid #: / D.O.B:
Age: / Sex: M F / Client Address: / Phone Numbers:
Language: English Spanish
Other: / School:
Grade:
Phone (if avail):
Mother: / Phone: / Address: / Parents Married/together? Yes No
Father: / Phone: / Address:
Guardian:
Relationship: / Phone: / Address:

Summary of Referral Reasons:

CHILD/FAMILY Referral Needs:

SERVICES / # of Hours / SERVICES / # of Hours
Service Needs / Therapy Services
Behavioral Health Screening / Individual
Diagnostic Assessment-Initial / Group
Diagnostic Assessment- follow up / Family w/o client
Psychological Testing/ Evaluation / Family w/ client
Comprehensive Evaluation – Initial / Community Support Services
Comprehensive Evaluation – Follow up / Crisis Management
Alcohol & Drug Assessment – Follow up / Medication Management
Treatment Plan Development and Motivation Services / Rehab Psychosocial Service
Service Plan Development (Mental Health) / Behavior Modification (BMod)
Service Plan Development (Team w/ client) / Family Support
Service Plan Development (Team w/o Client) / Peer Support

Additional Comments: ______

1