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Mental Health & Trauma Treatment Services Form

Mental Health & Trauma Treatment Services Form icfs-web 2020-05-12T17:40:57+00:00

*Indicates a required field

Referring person: *

First

Middle

Last

Referral Date: *

Relationship to client: *

Agency Name/Address:

Phone *

Client Name *

First

Middle

Last

Client Date of Birth:

Client Primary Language:

English
Spanish
Other

Other Language:

Parent Name:

First

Middle

Last

Relationship to client: *

Parent
Legal Guardian
Caregiver

Name (if not parent):

Preferred Language:

English
Spanish
Other

Home Phone:

Cell Phone:

Work Phone:

Email:

Address:

Insurance Status: *

Medi-Cal
Other Insurance
Unknown
None

Medi-Cal # (if applies):

Issue Date:

Other Insurance/Name/#

Active Date:

School District:

Teacher's Name:

Grade:

School Name:

School Level: *

Elementary
Jr. High
High School

Reason Services are Being Requested: *

Family History of:

Mental health concerns
Incarceration
Substance abuse
Domestic violence
Unknown

Experienced a natural disaster:

Yes
No
Unknown

If yes, type:

Experienced/witnessed abuse, violence, trauma, or neglect? *

Yes
No
Unknown

Client history of mental health treatment/intervention? *

Yes
No
Unknown

Danger to self or others in the last 30 days? *

Yes
No
Unknow

If Yes, please describe: *

Bizarre/unusual behavior in the last 30 days? *

Yes
No
Unknown

If Yes, please describe: *

I understand that my child is being referred to Interface Children & Family Services for mental health services. I understand that my participation with my child is essential. I hereby give my consent for the exchange and release of information for this purpose. You may contact me on my: *