REFERRAL FOR INDIVIDUAL & FAMILY COUNSELING


CLIENT INFORMATION

CLIENT LEGAL NAME*
CLIENT DATE OF BIRTH*
IS CLIENT A MINOR?*
ASSIGNED SEX AT BIRTH*
GENDER IDENTITY*
PRIMARY SPOKEN LANGUAGE AT HOME (CHECK ALL THAT APPLY)*
WHERE IS CLIENT CURRENTLY RESIDING?*
CLIENT ADDRESS*
SPECIFY "NONE" IF CLIENT DOES NOT HAVE COVERAGE OR IF CLIENT CHOOSES TO PAY OUT OF POCKET FOR SERVICES
WHO ARE MINOR'S CAREGIVERS? WHO IS LEGALLY RESPONSIBLE FOR MINOR? WHO HAS PHYSICAL CUSTODY OF THE CLIENT? DOES CLIENT HAVE MORE THAN 1 OR 2 CAREGIVERS? ARE CAREGIVERS MARRIED OR LEGALLY SEPARATED, DIVORCED? IS THERE A DESIGNATED LEGAL GUARDIAN?
DOES CLIENT HAVE MORE THAN ONE LEGALLY RESPONSIBLE ADULT?*
RELATIONSHIP TO CLIENT*

REFERRAL INFORMATION

REFERRAL SOURCE RELATIONSHIP TO CLIENT*
ARE MENTAL HEALTH ASSESSMENT OR SERVICES MANDATED OR OTHERWISE REQUIRED?*
DOES CLIENT HAVE CURRENT INVOLVEMENT WITH COURT OR LEGAL SYSTEM?*
DOES CLIENT HAVE CURRENT INVOLVEMENT WITH DJJ ?*
SERVICES REQUESTED (CHECK ALL THAT APPLY)*

PROBLEM SEXUAL BEHAVIOR HISTORY AND SCREEN

FOR ALL REFERRALS FOR ASSESSMENT OR TREATMENT OF PROBLEMATIC SEXUAL BEHAVIOR, PLEASE INCLUDE A COPY OF ANY OF THE FOLLOWING MATERIALS AS APPLICABLE TO THE REFERRAL FOR ASSESSMENT OR TREATMENT:

  • INFORMATION REGARDING DJJ INVOLVEMENT, ADJUDICATION OR PENDING CHARGES
  • CURRENT AND RECENT MENTAL HEALTH PROVIDERS
  • PSYCHOLOGICAL ASSESSMENTS AND REPORTS
  • MENTAL HEALTH RECORDS, TREATMENT PLANS AND ASSESSMENTS
  • IEP REPORT OR SCHOOL RECORDS, IF APPLICABLE
  • CME REPORT

PLEASE NOTE: WE CAN NOT SCHEDULE AN INITIAL APPOINTMENT TO BEGIN ASSESSMENT/TREATMENT FOR PROBLEMATIC SEXUAL BEHAVIOR UNTIL ALL REQUESTED DOCUMENTATION HAS BEEN RECEIVED.

DOES CLIENT HAVE ANY PENDING LEGAL CHARGES?*
IS CLIENT COURT ORDERED OR OTHERWISE REQUIRED TO RECEIVE AN EVALUATION FOR PROBLEMATIC SEXUAL BEHAVIOR?*
HAS CLIENT HAD A PREVIOUS PROBLEMATIC SEXUAL BEHAVIOR OR PSYCHOSEXUAL ASSESSMENT PREVIOUSLY?*
IF YES, SPECIFY WHEN AND WHERE/BY WHOM:
TO YOUR KNOWLEDGE, HAS CLIENT EVER INITIATED PROBLEMATIC SEXUAL BEHAVIORS WITH OTHERS?*
TO YOUR KNOWLEDGE, HAS CLIENT EVER USED COERCION OR FORCE WHEN ENAGING IN PROBLEMATIC SEXUAL BEHAVIORS?*
IS ASSESSMENT FOR PROBLEMATIC SEXUAL BEHAVIOR BEING REQUESTED TO DETERMINE CLIENT'S TREATMENT RECOMMENDATIONS OR PLACEMENT?*

TRAUMA SCREEN

SPECIFY ALL KNOWN OR SUSPECTED ADVERSE EXPERIENCES:*
SPECIFY ALL KNOWN OR SUSPECTED ADVERSE EXPERIENCES:
  KNOWN/CONFIRMED SUSPECTED NONE/DENIED UNKNOWN
IF NO ABUSE OR TRAUMA, PLEASE SELECT CONFIRMED AND CONTINUE TO THE NEXT SECTION
PHYSICAL ABUSE
SEXUAL ABUSE
EMOTIONAL OR PSYCHOLOGICAL ABUSE
NEGLECT OR DEPENDENCY
BULLYING
HATE CRIME OR THREAT BASED ON IDENTITY
SCHOOL VIOLENCE
COMMUNITY VIOLENCE
REMOVAL FROM THE HOME
TRAUMATIC SEPARATION FROM CAREGIVERS OR KIDNAPPING
MAJOR ACCIDENT OR ILLNESS
WAR AND/OR TERRORISM
INTIMATE PARTNER ABUSE AND/OR VIOLENCE
WITNESS TO DOMESTIC VIOLENCE
TRAUMATIC GRIEF
NATURAL OR MANMADE DISASTER
RACIAL/HISTORICAL TRAUMA
DEVELOPMENTAL ATTACHMENT TRAUMA
HAS CLIENT EVER COMPLETED A FORENSIC INTERVIEW?*

FOR DJJ-INVOLVED REFERRALS ONLY

LEGAL STATUS OF CLIENT AT THE TIME OF REFERRAL:*
NAME OF COURT COUNSELOR, IF DIFFERENT FROM REFERRAL:

INCLUDE A COPY OF ANY OF THE FOLLOWING MATERIALS AS APPLICABLE TO THIS REFERRAL:

  • COURT JUDGEMENT
  • COURT ORDER
  • ARREST REPORT
  • WITNESS STATEMENT
  • POLICE REPORTS
  • OFFENDER STATEMENT
  • VICTIM STATEMENT
  • CME
  • OTHER RELEVANT RECORDS

SUBMISSION

DATE OF REFERRAL*

TFS IFC e-Referral Revised and Published 09/15/2022

FOR OFFICE USE ONLY
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