Referral Form

Referral Source/Agency: ----- School district Anderson 1

Case Manager/Referral Agent's Name:

Case Manager/Referral Agent's Address:

Case Manager/Referral Agent's Phone:

Case Manager/Referral Agent's Email:

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 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?

If not, where and with whom is the child currently living?

Primary language spoken by family:

Are there any safety concerns with aggressive behavior that would impact our staff or the ability for the child to be seen?

Does this child have a valid IEP?

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:

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?
School-based referrals MUST have Medicaid.

Client Medicaid #:

SC Medicaid MCO Type:

No Insurance / Self Pay

Behavioral Concerns For This Referral:

If "Other", please explain:

Additional Information: (limit 300 characters)

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.