EFS Referral Form

Counseling / Assessment Intake
Patient Demographics
Legal Name*

First NameMiddle NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Primary Insurance Number
Primary Insurance Type
Secondary Insurance Number
Secondary Insurance Type
Social Security Number
Referred Patient is an Adult?*

YesNo
Parent / Guardian*

First NameLast Name
Relationship
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Alternate Phone Number
Emergency Phone Number
Email*
example@example.com
Ethnicity*
Primary Language
Medical / Psychiatric History
Previous Psychiatrist
Contact Info
Current Medications
Compliant?

YesNo
Prescribed By
Number of Hospitalizations
Last Date / Extent
Self-Mutilation?

YesNo
Last Time
Suicidal Ideation

YesNo
Last Ideation
Attempts

YesNo
Last Attempt
History of Substance Abuse

YesNo
Date of Last Use

MonthDayYear
Date
Substance(s) of Choice
Frequency

DailyWeeklyMonthlyRarelySociallyNever
Any Other Health Conditions

YesNo
Explain
For example, hypertension, diabetes, high blood pressure, seizures, etc.
Chief Complaint

*REFERRAL IS INCOMPLETE WITHOUT THIS SECTION COMPLETED*
Brief History, Presenting Problem(s), Current Diagnosis*
Symptom / Problem Checklist*

Physical / Verbal AggressionAnxietyConduct ProblemsDepressed MoodElevated MoodFamily ProblemsGender IssuesGriefHyperactivityIndependent Living ProblemsIrritabilityMood SwingsOppositional / Defiant BehaviorsPoor ConcentrationPoor Interpersonal SkillsPoor JudgementPTSD/TraumaHome / Work / School ProblemsSelf-Harming / Dangerous BehaviorsThoughts of SuicideHistory of AbuseWorthlessnessAt-Risk of Legal SystemSubstance UseCourt OrderedSexually Acting Out
Referred By*
Contact Info*
*** REFERRAL is COMPLETE, unless the referral source is DFCS, Court, DJJ, or Mental Health Agency; please continue ***

If this is NOT a DFCS, Court, DJJ, or Mental health Agency referral, scroll to the bottom and click Submit.
DFCS / Foster Care, Court / DJJ or Mental Health Hospital, PLEASE fill out the portion that pertains to your entity type.
DFCS / Foster Care Referral
Department of Family & Children Services Case

YesNo
Supporting Documents

Browse Files
Completed CCFA, Trauma Assessment, Psychological, etc. Cancelof
County
Case Manager Name
Phone Number
Fax Number
Case Manager Email
Supervisor's Name
Placement Information (if other than Biological Parent or Legal Guardian)

Please submit copy of Guardianship / Placement Agreement
Supporting Documents

Browse Files
Guardian/Placement Agreement Cancelof
Name or Agency
Contact Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type

Group HomeFoster HomeTemp HousingExtended HousingNon-Relative (Fictive Kin)
Dept. of Juvenile Justice / Court Referral
Court Ordered? (Drug Court, Dept. of Juvenile Justice, etc.)

YesNo
Supporting Documents

Browse Files
Completed CCFA, court recommendations, probation order, etc. Cancelof
County
Probation Officer Name
Probation Officer Phone
Probation Officer Fax
Probation Officer Email
example@example.com
Supervisor's Name
Presenting Charge / Offense
Next Court Date

MonthDayYear
Date
Mental / Behavioral Health Hospital Referral
Mental/Behavioral Health Hospital Referral?

YesNo
Supporting Documents

Browse Files
Admission paperwork, discharge summary, last progress note, etc Cancelof
Name of Facility
Phone Number
Fax Number
Admission Date

MonthDayYear
Date
Discharge (Anticipated) Date

MonthDayYear
Date
Presenting Problems at Time of Admission
Discharging Therapist
Direct Contact Number
Medications Prescribed
Discharging Mental Health Diagnosis(es)
Supporting Documents

Browse Files
Please submit any documentation supporting the above diagnosis(es) Cancelof
Admin Notes
Notes:
Should be Empty:

Counseling / Assessment Intake

Patient Demographics

Medical / Psychiatric History

Chief Complaint

DFCS / Foster Care, Court / DJJ or Mental Health Hospital, PLEASE fill out the portion that pertains to your entity type.

DFCS / Foster Care Referral

Dept. of Juvenile Justice / Court Referral

Mental / Behavioral Health Hospital Referral