Referral Information Please Include W/Referral

At Allen Brooks Professional Counseling, we aim to provide purpose, motivation, and direction to our community’s youth, our community’s families, and our community’s elderly by restoring hope, and offering a range of alternatives and coping skills to enjoy life.

Referral Information Please Include w/Referral:

Date/Time of Referral

Referring Worker

Agency

Phone Number

Service Requested

Client Information

Client Name DOB:

Client Race: Client Gender: M / F Marital Status:

Client Insurance: Client Insurance #:

Client Medical Record # SSN:

Client Phone Number(s) home work/cell

Client Address

Name of Guardian(s)

Relationship to Client

Medical and Emergency Information (Update annually)

Person to Contact in Case of Emergency:

Emergency Contact Relationship to Client:

Emergency Contact Phone Number

Emergency Contact Address:

Client allergies (list) None Known

Client’s Physician: Physician Phone:

Current Client Medications and Dosage

What Other Agencies/Service Providers are involved with client?

Name of Agency/Provider / Contact Name / Contact Phone Number
School Currently Attending / Contact Name / Contact Phone Number