Referral Form

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?

If so, what was the family's response?

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 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

Accommodations Needed:

Is the client covered under parent's private/commerical insurance?

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?

Client Medicaid #:

Client Insurance Type: ----- Medicaid - Select Health Medicaid - Blue Choice Medicaid - Cenpatico Medicaid - Molina Medicaid - Humana Blue Cross Blue Shield Other

Behavioral Concerns For This Referral:

If "Other", please explain:

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.