House Calls Counseling - Referral Form for Professionals

To Refer Someone for Services:

Please click HERE for assistance.

Please Note: this form is not currently functioning.

Thank you for your assistance.

Client(s)

Other(s) Living in the Home

Full Name (First & Last)	Age	Address	Relationship to client	How long has this person lived with caregiver?

Information

What are the primary concerns of the person making the referral? How will s/he know when client(s) no longer need therapy?

If the client(s) have had prior treatment, what was the diagnosis, the outcome, who was the therapist/organization providing treatment and when did treatment occur?

How is the client(s) doing in in school/work:

How will the services be paid? We do not accept Medicaid or Public Aid funding at this time.

Parent and Child Welfare, as applies

Tell us about the client(s) biological mother (current involvement with client; history of substance abuse &/or mental illness & treatment; other children)

Tell us about the client(s) biological father (current involvement with client; history of substance abuse &/or mental illness & treatment; other children)

When did client enter Child Welfare system & why?

What is the permanancy goal or plan for the client and when do you anticipate it will be implemented?

Please list the client(s) placements including timeframes and reasons for discharge if known:

Upon submitting the form, you will be directed back to the main index.

Thank you.