Request for Service Intake
Date of Referral
How did you hear about us?
Referral Contact
DEMOGRAPHIC INFORMATION
Name
Last 4 OF SS#
Gender
---
MALE
FEMALE
Birthdate (mm/dd/yy)
Address
City
STATE
Name of School
Current Grade
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Dismissal Time
Parent/Guardian Name
Contact Information
Day
Is it okay to leave a voicemail?
---
YES
NO
Insurance Type
Insurance Number
STATEMENT OF CONCERN
Reason for
Seeking Services
Has Consumer tried other interventions for issue mentioned above from school, counselors, psychiatrist etc.?
If so, please list company/name
Outcome
Additional company/name
Outcome
Instability of Care Provider Supervision
None
Mild
Moderate
Severe
Any safety issues in Living Arrangement?
None
Mild
Moderate
Severe
Aggression or Self Injurious Behaviors
None
Mild
Moderate
Severe
Consumer's Current Risk to Self
None
Mild
Moderate
Severe
Consumer's Potential Risk to Others
None
Mild
Moderate
Severe
Use of Substances?
---
YES
NO
If so, please list
Has Consumer ever had any Suicide Attempts?
---
YES
NO
(Plan/Ideation)
History of Abuse?
---
YES
NO
If so, please explain:
Legal Involvement?
---
YES
NO
If so, please explain:
Has the Consumer used mental health services in the past?
Yes
No
I don't know
If so, where?
Any other safety concerns:
Currently having difficulties in school
---
YES
NO
Has IEP/Behavioral Plan of Any Type been given
---
YES
NO
If so, date:
Are you currently on any medications
---
YES
NO
If so, please list:
Known Allergies
Primary Care Physician Name/Clinic
Contact
Date available to come in for Prescreening
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Additional Information, Comments, or Questions
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