Franklin County Provider Referral
Which provider would you like to refer to?
Preferred Family Healthcare
Lutheran Family and Children's Services
St. Louis Counseling
Date of Birth
Can a message be left?
Referral Source Contact Number
Referral Source E-mail
School Child Attends
Other Community Agencies Involved
Check all that apply and that are known
Crider Health Center
Division of Youth Services
Substance Abuse Services
Reason for Referral
Please include diagnosis, behaviors, and other relevant information
Release of Information
Release obtained by:
Date Release obtained:
Name of Parent/Guardian Release obtained from:
By checking the below box, I, the referring agency/school personnel acknowledge that I have been given permission by the parent/guardian of the child listed above to communicate with agency being referred to for the purpose of providing above listed child(ren) supportive services.
I agree to the above statement
******PRIVATE AND CONFIDENTIAL******
This transmission and any attached files are privileged, confidential or otherwise the exclusive property of the intended recipient or the Franklin County System of Care. If you are not the intended recipient,any disclosure, copying, distribution or use of any of the information contained in or attached to this transmission is strictly prohibited. If you have received this transmission in error, please contact me immediately by e-mail (
) or telephone (636-234-7133) and promptly destroy the original transmission and its attachments. Opinions, conclusions and other information in this message that do not relate to the official business of the Franklin County System of Care shall be understood as neither given nor endorsed by it.
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