• Counseling / Assessment Intake

    Counseling / Assessment Intake

  • Patient Demographics

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  • Medical / Psychiatric History

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  • Chief Complaint

    *REFERRAL IS INCOMPLETE WITHOUT THIS SECTION COMPLETED*


  • *** 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

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  • Placement Information (if other than Biological Parent or Legal Guardian)

    Please submit copy of Guardianship / Placement Agreement

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  • Dept. of Juvenile Justice / Court Referral

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  • Mental / Behavioral Health Hospital Referral

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  • Should be Empty: