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Referral Form
To make a referral for services, please fill out the form below, and click the Send button.
Referral Source
Referral Source/Agency:
Case Manager/Referral Agent's Name:
Case Manager/Referral Agent's Phone:
Case Manager/Referral Agent's Email:
Case Manager/Referral Agent's Fax:
Have you informed the family you are making this referral?
Yes
No
If so, what was the family's response?
Client Info
Client First Name:
Client Middle Name:
Client Last Name:
Client Date of Birth:
Client Marital Status:
Divorced
Domestic Partner
Legally Separated
Married
Single
Widowed
Other
Client Sex At Birth:
-----
Female
Male
Primary Language Spoken by Client:
-----
ASL
Spanish
English
Client Race:
-----
American Indian or Alaska Native
Asian
Bi-Racial
Black or African American
Caucasian
Hispanic or Latino
Indian
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
Other
Client School Location:
-----
Palmetto High
Powdersville High
Wren High
Palmetto Elementary
Cedar Grove Elementary
Concrete Primary
Wren Middle
West Pelzer Elementary
Spearman Elementary
Palmetto Middle
Wren Elementary
Hunt Meadows Elementary
Powdersville Middle
Powdersville Elementary
Does this child live at home?
-----
Yes
No
If not, where and with whom is the child currently living?
Are there any safety concerns with aggressive behavior that would impact our staff or the ability for the client to be seen?
Legal Guardian Info
Legal Guardian First Name:
Legal Guardian Last Name:
Legal Guardian Address 1:
Legal Guardian Address 2:
Legal Guardian City:
Legal Guardian State:
(Only 2 characters, for example: "SC")
Legal Guardian Zip:
Legal Guardian Phone:
Legal Guardian Email:
Do you approve electronic communication (text/email)?
-----
Yes
No
Primary Language Spoken by Legal Guardian:
-----
ASL
Spanish
English
Insurance Info
Accommodations Needed:
Physical Modifications
Telehealth
Translator
Is the client covered under parent's private/commerical insurance?
Yes
No
Legal Guardian Insurance Provider:
Legal Guardian Private Insurance Number:
Legal Guardian Name On Insurance:
Legal Guardian Date of Birth:
Is the client covered under Medicaid?
Yes
No
Client Medicaid #:
Client Insurance Type:
-----
Medicaid - Select Health
Medicaid - Blue Choice
Medicaid - Cenpatico
Medicaid - Molina
Medicaid - Humana
Blue Cross Blue Shield
Other
Reasons for Referral
Behavioral Concerns For This Referral:
Academic Difficulty
Autism and/or developmental delay
Lack of Social Skills
ADD/ADHD
Teenage Pregnancy
Defiance
Disruptive Behaviors and/or Conduct Disorder
Legal issues/Agency Involvement
Suspected or known Sexual Abuse
Suspected or known Neglect
Other Trauma and/or history of abuse
Sexually Inappropriate Behaviors
Substance/Alcohol Abuse Family
Suspected Substance/Alcohol Abuse Client
Domestic Violence
Grief/Loss Issues (Death; Divorce; Relocation; Separation from Parents)
Other adjustment disorders/issues
Anxiety and/or OCD
Specific Phobias
Anxiety or mood issue due to medical issue
Depression or other mood disturbance
Bipolar Disorder
Suicidal attempts, gestures, and/or self-harm
Eating Disorders
Bipolar D/O
Schizophrenia and/or other psychotic behaviors or features
Employment/Job Issues
Other Body Image/Self-Esteem Issues
Issues related to bullying; peer pressure
Homelessness
Gender Issues (Dysphoria; Identity; LGBTQ+)
Threat/Safety Assessment
Out of educational or home placement due to conduct
Anger Management
Placement Aftercare and/or Reunfication
Need for parent education/parent training
Relationship/Marital Issues
Other
If "Other", please explain:
Other Info
What Other Services/Agencies are currently being used or have been used in the past and to address what issue?
Date of last known Behavioral Health Screening:
Date Last DA Completed:
(If DA has been completed less than 6 months ago, please
fax or email a copy to us
, or
attach it to this form at the bottom
.)
Preferred CFS Location:
-----
Greenville
Spartanburg
Williamston
Desired Date and Time for Appointment:
Add Attachment:
Please inform parents to bring the following documents to first appointment:
Insurance Card(s); primary, secondary and tertiary insurance cards
Client’s Social Security Card
Parent’s Drivers License
An email confirmation will be sent to you once an appointment has been made.
Instruct parent to call to schedule an appointment, a follow-up call will be made if contact has not been made within a week of receipt of referral.
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