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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
Please enable JavaScript in your browser to complete this form.
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:
*
home phone
cell phone
text
email
I attest to the right to sign consent for this referral.
*
Click to confirm
I give verbal consent for contact and referral.
*
Click to confirm
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