To make a referral for services, please fill out the form below, and click the Send button.
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?
If so, what was the family's response?
Client First Name:
Client Middle Name:
Client Last Name:
Client Date of Birth:
American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Client Insurance Provider:
Client Medicaid #:
Does this child live at home?
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 Insurance Provider:
Legal Guardian Medicaid Number:
SC Medicaid MCO Type:
No Insurance / Self Pay
Reasons for Referral
Behavioral Concerns For This Referral:
Possible Sexual Abuse
Lack of Social Skills
Family in Need of Parenting Education
Grief/Loss Issues (Death, Divorce, Move, Etc)
Substance/Alcohol Abuse in Family
Sexually Inappropriate Behaviors
Placement Aftercare and/or Reunification
Autism and/or developmental delay
Suicidal attempts, gestures, and/or self-harming
Anxiety and/or OCD
Trauma and/or abuse history
Family system changes (divorce, adoption)
If "Other", please explain:
Service Plan Development
Approximate # of hours per week requested:
(limit 300 characters)
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?
Medication and Dosages:
Does the child have any educational, physical or mental health diagnoses?
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 that the CFS Counselor should know about when providing services? (dogs, guns, family history of violence, etc.)
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:
Form Completed By:
How did you hear about us?
Word of Mouth
Past or Current Client
Primary Care Provider
Additional info about how you found CFS:
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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In Home Family Services Referral Form
Outpatient Referral Form
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