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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 Address:
Case Manager/Referral Agent's Phone:
Case Manager/Referral Agent's Email:
Who should be contacted with the results of this referral?
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 Gender:
-----
Female
Male
Client Race:
-----
African American
American Indian/Alaskan Native
Asian
Asian Indian
Bi-Racial
Caucasian
Hispanic/Latino
Middle Eastern
Native Hawaiian/Pacific Islander
Client School:
Does this child live at home?
Yes
No
If not, where and with whom is the child currently living?
Primary language spoken by family:
Legal Guardian Info
Legal Guardian First Name:
Legal Guardian Middle Name:
Legal Guardian Last Name:
Legal Guardian Address 1:
Legal Guardian Address 2:
Legal Guardian City:
Legal Guardian State:
Legal Guardian Zip:
Legal Guardian Phone:
Legal Guardian Email:
Insurance Info
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 #:
SC Medicaid MCO Type:
No Insurance / Self Pay
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
Gender Issues
Bipolar D/O
Schizophrenia and/or othe 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:
Medical Concerns For This Referral:
Needs Medical Home/Pediatrician
Well Child Check
Immunization
Sick Visit
Hearing/Vision Screening
Sports Physical
Other
If "Other", please explain:
Service(s) Requested:
Comprehensive Assessment
Individual Therapy
Family Therapy
Crisis Management
Service Plan Development
Behavior Modification
RPS
Family Support
Medication Management
Pediatric/Medical Services
Food and Other Supplemental Information
Approximate # of hours per week requested:
Additional Information:
(limit 300 characters)
Other Info
What Other Services/Agencies are currently being used or have been used in the past and to address what issue?
Is the Child/Parent currently on medication?
Yes
No
Medication and Dosages:
Does the child have any educational, physical or mental health diagnoses?
Yes
No
If yes, please indicate what the diagnosis is:
What would you identify as the child's or family's strengths?
Are there any safety concerns with aggressive behavior that would impact our staff or the ability for the client to be seen in the office?
Date of last known Behavioral Health Screening (YYYY/MM/DD):
Date Last DA Completed (YYYY/MM/DD):
(If DA has been completed less than 6 months ago, please
fax or email a copy to us
.)
Preferred CFS Location:
-----
Greenville
Spartanburg
Williamston
Form Completed By:
How did you hear about us?
-----
Facebook
Instagram
Website
Word of Mouth
Past or Current Client
Primary Care Provider
Other
Additional info about how you found CFS:
Add Attachment:
Date:
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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