Agency Referral for Client
You may enter your personal information here and a Family Dynamics Representative will contact you for an appointment. The information you enter is confidential, however as with any electronic systems, your information may not be secure. Select (I Agree) to indicated that you acknowledge the limitation of protection of your information.
Select " I Agree" and continue.
Client's Middle Name
Enter Client's birthdate
Parent's Name (If Referral for Child)
Parent's Phone Number (If Referral For Child)
City, State and Zip Code
Contact Phone Number
Other contact numbers
How would they like to be contacted
check all that apply
Source of Payment
Do you have a Primary Care Physician?
If yes, who are you seeing?
What medications are you currently taking?
(Please include supplements)
The following information is optional.
This information may help us serve you better.
Check all that apply
Feelings of hopelessness
Lack of energy or can't get out of bed
Lack of enjoyment
Feelings of sadness or emptiness
Loss of appetite or weight loss
Increase appetite or weight gain
Crying a lot
Irritable or angry
Change in sexual interest/behavior
Rapid heart rate
Sudden feelings of panic
Feeling like you can't breathe
Experienced a traumatic or life threatening event
Flashbacks or Feeling like the event is happening over again
Avoiding activities associated with trauma
Afraid to leave home or go places
The following items are associated with behavior
I feel like I need to leave when I am in a crowed room
Violent behavior -- Excessive anger
Binge eating or restricting food
Unable to relax
Thoughts of hurting yourself
Thoughts of hurting others
Sexual behavior problems
Feeling like I am out of control
Substance abuse history
Please indicate past or current substance abuse history
Abused medications prescribed to me
How frequently used?
How much did you (client) use?
When was last time you (client) used?
Did you (client) have a recent move, job change or loss in a relationship?
Name of Agency submitting Referral.
(Check box below if not stated check other & type Your Name
One Safe Place
Anthem Blue Cross
Triple P Practitioner
Name of person from Agency submitting referral
Contact # ( Any Other information)
DO NOT EXIT BEFORE SEE THE "Your response has been recorded"
(If not a field that is required will show in red please go back through form & fill out then re-submit)
Office Use only
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service