INTECELLE REFERRAL FORM

REFERRAL FORM
Name*
Age
DOB*

MonthDayYear
Date
Male

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*

Area CodePhone Number
Email
example@example.com
Secondary Phone

Area CodePhone Number
Leave Messages

YesNo
If Minor, where does the child currently reside?

Both ParentsMomDadJoint Custody (Specify below)Other
Joint Custody Arrangement
Parent/Guardian's Name
Relationship
Current Address
Phone
Parent/Guardian's Name
Relationship
Current Address
Phone
Type of Insurance

MedicaidChildNetSelf Pay
Policy / Member ID*
(N/A if Self Pay is selected
SSN
Referring Agency
Date

MonthDayYear
Date
Referral Name
Title
Phone
Fax
Reason for Referral (check all that applies):
Symptom

DeathDivorceSleep ProblemsChild NeglectSexual AbuseDrug AbuseCustodySuicidal ThoughtsCrime VictimParentingOther
Symptom

AngerDepressionPoor HealthFinancialLegal IssuesSelf-EsteemChild AbuseRun AwayAnxietyOther
Symptom

Domestic ViolenceFamily ConflictsSocial SkillsTruancyMedicationMental IllnessHomeless
Service(s) Requesting

Individual TherapyAnger ManagementPsychiatric EvaluationFamily TherapyParentingSubstance Abuse CounselingSubstance Abuse EvaluationBiopsychosocial
Court Ordered?

YesNo
Court Date

MonthDayYear
Date
If Evaluation, need by
Previous behavioral / mental health treatment

YesNo
Where
For what
Successfully Completed

YesNo
Is this referral pending acceptance elsewhere?

YesNo
Preferences for treatment
Primary Language
Therapist

MaleFemale
OfficeHomeSchoolMorningAfternoon/EveningWeekdaysWeekends
Therapist Assigned
Staff Signature

Clear
Community Behavioral Health Services for Adults & Children 8333 W McNab Rd Suite 110 Tamarac, Fl 33321 | Ph. 954-756-9709 Fax 954-756-9710
Should be Empty:

REFERRAL FORM

Preferences for treatment