Referral Form for an Adult
If you would like to refer yourself or another adult, please complete the information below.  This information will help Heather Risk, PsyD & Associates, PLLC in ensuring you needs are met.  After receiving the following information, we will contact you to discuss any questions and take the next steps to beginning services.
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Today's Date
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Client's Name: *
Gender:
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Date of Birth:
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Age:
Address: Street, City, State, Zip Code
Work Phone: ### - ### - ####
Can we leave a message at this contact? (Work)
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Cell Phone: ### - ### - ####
Can we leave a message at this contact? (Cell)
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Home Phone: ### - ### - #### *
Can we leave a message at this contact? (Home)
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Email Address:
Emergency Contact Information
Who can we contact in case of an emergency?
Name:
Phone: ### - ### - ####
Relationship
Who is completing this form?
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Name:
Relationship:
Phone: ### - ### - ####
Email:
Why are you seeking an assessment and/or treatment? Please be as specific as you can as you explain your concerns, when the concerns began, and your goals for services
Have you (or the person you are referring) experienced any history of trauma, abuse, or maltreatment?  If so, please explain:
Have you (or the person you are referring) ever made any suicide attempts or demonstrated violent behavior?  If so, please describe (age, reasons, circumstances, behaviors, etc.):
Have you (or the person you are referring) received therapy in the past?  If so, please provide a brief description of the services received, reason for services, provider or agency name, and why services ended):
Specify any medication you (or the person you are referring) are currently taking and for what:
Is there any additional information you think we should know before beginning services?  Do you have any questions?
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