THE EMPOWERMENT CENTER (TEC)

Referral for Services Form (Complete)

Date of Referral: ____ / ____ / ______

REFERRAL SOURCE INFORMATION

Referral Source/Agency Name: __________________________________________
Referral Contact Person: __________________________________________
Referral Phone Number: __________________________________________
Referral Email Address: __________________________________________
Preferred Method of Contact: ☐ Phone ☐ Email

CLIENT INFORMATION

Client Full Name: _________________________________________________
Date of Birth: ____ / ____ / ______
Phone Number: _________________________________________________
Alternate Phone Number: _________________________________________
Email (if available): ____________________________________________

Current Address / Location (if applicable):

Best Time to Contact Client: ☐ Morning ☐ Afternoon ☐ Evening
Preferred Contact Method: ☐ Call ☐ Text ☐ Email ☐ Other: __________

Emergency Contact Name: _________________________________________
Emergency Contact Phone: ________________________________________
Relationship: _________________________________________________

CLIENT STATUS / CURRENT SITUATION

Current Living Situation:
☐ Stable Housing ☐ Transitional Housing ☐ Shelter ☐ Homeless ☐ Unknown ☐ Other: __________

Is the client currently employed? ☐ Yes ☐ No ☐ Unknown
Does the client have insurance? ☐ Yes ☐ No ☐ Unknown
If yes, type of insurance: ☐ Medicaid ☐ Medicare ☐ Private ☐ Other: __________

SERVICES REQUESTED (Check All That Apply)

☐ Assertive Community Treatment (ACT)
☐ Partial Hospitalization Program (PHP)
☐ Mental Health Skill-Building / Community-Based Support
☐ Psychosocial Rehabilitation (PSR)
☐ Peer Support Services
☐ Care Coordination / Resource Linkage
☐ Community Engagement / Socialization Support
☐ Employment/Vocational Support
☐ Housing Stability Support
☐ Residential Sponsorship
☐ In-Home Supports
☐ Other Requested Services: __________________________________________

PRESENTING NEEDS / REASON FOR REFERRAL

Brief description of the reason for referral:

Primary goals the client wants support with:
☐ Emotional regulation / coping skills
☐ Daily routine / ADLs / stability
☐ Medication support / compliance reminders
☐ Social skills / building healthy relationships
☐ Community resources (housing, food, ID, benefits)
☐ Employment/education support
☐ Safety planning / crisis prevention
☐ Other: __________________________________________________________

CLINICAL INFORMATION (IF AVAILABLE)

Diagnosis/Diagnoses (if known):

Current Symptoms/Concerns: (check all that apply)
☐ Anxiety ☐ Depression ☐ Mood swings ☐ Trauma-related symptoms
☐ Psychosis / hallucinations ☐ Paranoia ☐ Mania ☐ Sleep issues
☐ Substance use concerns ☐ Anger/impulsivity ☐ Isolation
☐ Other: __________________________________________________________

Current Mental Health Provider (if any): ____________________________
Current Medications (if known): ____________________________________

RISK / SAFETY INFORMATION

History of Crisis Hospitalization (past 12 months): ☐ Yes ☐ No ☐ Unknown
Current Safety Concerns: ☐ Yes ☐ No ☐ Unknown
If yes, explain briefly:

Any known triggers, aggression risk, or safety concerns for staff?
☐ Yes ☐ No ☐ Unknown
If yes, explain:

LEGAL / SYSTEM INVOLVEMENT (IF APPLICABLE)

☐ Probation/Parole ☐ Court involvement ☐ CPS involvement ☐ None ☐ Unknown
Additional details:

DOCUMENTS ATTACHED (Check All That Apply)

☐ Discharge Summary
☐ Psychological Evaluation
☐ Treatment Plan / Service Plan
☐ Medication List
☐ Insurance Information
☐ ID / Demographics
☐ Other: __________________________________________________________

CLIENT CONSENT (IF APPLICABLE)

☐ Client is aware of and agrees to the referral
☐ Client is not aware / referral initiated by guardian or agency
☐ Unable to confirm at this time

Releasing Information To TEC: ☐ Yes ☐ No
ROI On File: ☐ Yes ☐ No ☐ Pending

NOTES / ADDITIONAL INFORMATION

TEC INTAKE USE ONLY

Referral Received By: __________________________________________
Date Received: ____ / ____ / ______
Status: ☐ Pending ☐ Scheduled ☐ Completed ☐ Unable to Reach ☐ Declined
Follow-Up Date: ____ / ____ / ______
Assigned Staff: ________________________________________________

✅ SUBMIT REFERRALS TO:

The Empowerment Center (TEC)
📧 Email: info@vaempowermentcenter.com
📞 Phone: 757-990-3684
🌐 Website: www.vaempowermentcenter.com