Referral Form for a Child / Adolescent
If you would like to refer a child or adolescent for an assessment or treatment, please complete the information below. This information will help Heather Risk PsyD & Associates, PLLC in ensuring your child's needs are met. After receiving the following information, we will contact you to discuss any questions and take the next steps to beginning services.
Today's Date:
MM
/
DD
/
YYYY
What is the child's name?
Your answer
Gender:
Date of Birth:
MM
/
DD
/
YYYY
Age:
Your answer
Current Grade:
Your answer
Caregiver(s) / Legal Guardianship Contact Information
Please include complete accurate information - You may place an asterisk (*) next to preferred methods of contact.
Caregiver(s) / Legal Guardian(s):
Your answer
Relationship to child:
Address:
Your answer
Home Phone:
Your answer
May we leave a message at this contact?
Cell Phone:
Your answer
May we leave a message at this contact?
Work Phone:
Your answer
May we leave a message at this contact?
Email Address:
Your answer
May we leave a message at this contact?
Is there a DCBS Worker/Child Welfare Worker working with this child or family?
If yes, DCBS Worker's Name:
Your answer
(DCBS) Phone Number:
Your answer
(DCBS) Email:
Your answer
If no, has DCBS / Child Welfare worked with this child / family in the past?
Who has custody of this child, currently?
Your answer
Has this child ever been in the custody of another caregiver?
If yes, please explain:
Your answer
Who is completing this form? (Name)
Your answer
Phone:
Your answer
Email:
Your answer
Relationship to child:
Your answer
What type of service(s) are you seeking for this child?
Why are you seeking an assessment and/or treatment for this child? Please be as specific as you can as you explain your concerns, when the concerns began, and your goals for services.
Your answer
Has this child experienced any history of trauma, abuse, or maltreatment? If so, please explain the history.
Your answer
Has this child ever made any suicide attempts or demonstrated violent behavior? If so, please describe (age, reasons, circumstances, behaviors, etc.)
Your answer
Has this child received therapy in the past? If so, please provide a brief description of the services they received, reason for services, provider or agency name, and why services ended
Your answer
Specify any medication the child is currently taking and for what:
Your answer
Is there any additional information you think we should know before beginning services?
Your answer
Do you have any questions?
Your answer
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