Language
English (US)
Spanish (Latin America)
Referral Form
Hey there! We're so glad you're here at Family Solutions! Taking the first step towards taking charge of your mental health is a huge accomplishment, and we're here to cheer you on every step of the way. Whether you're looking for a friendly chat to explore some options, or you're ready to dive headfirst into beginning our program we've got you covered. This referral form is the first step to improving your life. Once you have completed this form we'll get you matched up with a case manager or therapist to help you reach your goals. Let's get started! If you have any questions or issues while completing this form please call us for assistance.
Today's Date
*
-
Month
-
Day
Year
Date
Client Demographics
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Marital Status:
*
Married
Never Married
Separated
Divorced
Remarried
Widowed
Race:
*
White
Black/African American
Asian/Pacific Islander
American Indian
Other
Ethnicity:
*
Hispanic
Non Hispanic
Sex:
*
Male
Female
Other
Veteran:
*
Yes
No
Social Security Number:
Type of Insurance or Payment Method
Please Select
Medicaid Insurance
Commercial Insurance (Coming Soon)
Self-Pay (Houston Only)
Unsure
Insurance Provider:
*
Insurance Number:
School (if applicable):
*
List Full Name of School and School District or N/A.
Last Grade or Degree Completed:
*
Client's Phone Number
*
Please enter a valid phone number.
Client Email:
*
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's current living situation:
*
Adult only
Adult: Relative
Adult: Non-Relative
Child: Both Parents
Child: One Parent
Child: Relative
Child: Foster Family
Widowed
Reason for Referral:
*
Needs/Risk Assessment/Behavior (Check all that apply):
When assessing the needs, risk, and behavior of presenting symptoms, the following factors are commonly considered. Please check all that apply:
*
School Suspension/Expulsion/Alternative School Placement
Out-of-Home Placement
Physical Aggression
Verbal Aggression
Argues with Adults/Authority
Significant Peer Difficulties/FightsPeer/Siblings
Family Violence
Bullies/Threatens
Suicidal Indentations/Threats
Physical Abuse
Property Destruction
Truancy
Defiant Behaviors
IQ Testing
Self-Injurious Behaviors
Fire Setting Behaviors
Difficulty Sleeping
Homicidal Ideations
Sexual Abuse
Steals
Substance Abuse
Alcohol Abuse
Difficulty Following Directions
Neuropsychological Testing
IEP Plan
BED Plan
504 Plan
Medication Management
Court-Mandated
Other
Parent or Legal Guardian Information
Parent/or Legal Guardian (if applicable):
*
First Name
Last Name
Email
*
example@example.com
Mobile Phone:
*
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.
Alternative Phone:
Please enter a valid phone number.
Please indicate whether the contact information above is for the client’s legal guardian or biological parent.
*
Yes
No
Other
If you are not the biological parent of the child, can you provide one or more of the following documents to verify legal guardianship? A copy of the child’s birth certificate showing your name, A legal custody agreement, A court order establishing guardianship, A notarized power of attorney for guardianship, Adoption paperwork, Affidavit of guardianship, Foster care placement documents (if applicable), or School enrollment forms listing you as guardian (may be used in conjunction with another document)
*
Yes
No
What is the legal guardian/biological parent preferred language?
*
English
Spanish
Other
Referral Source Contact Information
Name of Person Submitting Referral Form:
*
First Name
Last Name
Relation to the client
*
Ex: Parent, Relative, Spouse or Professional Support
Individual or Agency
*
Write self-referral if you are referring your child or guardian. Otherwise, please list the name of the company or school you work for.
Referral Source Phone Number:
*
Please enter a valid phone number.
Referral Source Email:
*
example@example.com
For a minor client, was the Parent or Legal Guardian notified of this referral?:
*
Yes
No
N/A; Client is over 18 or does not have a guardian
Does the Client Receive Services From Another Mental Health Provider? (If so, they need to be discharged from their current provider)
*
Yes
No
Are the Services Currently discontinued?
*
Yes
No
Has the client been hospitalized or participated in a Partial Hospitalization Program (PHP) or Intensive Outpatient Program (IOP) within the last 30 days?
*
Yes
No
Which office location is closest to you? Please choose one.
*
Cincinnati, OH - 3425 North Bend Rd, Suite F, Cincinnati, OH 45239
Columbus, OH - 1550 Old Henderson Road, Suite N-271
Bedford Heights, OH - 5198 Richmond Rd, Bedford Heights, OH 44146
Houston, TX - 350 N. Sam Houston Parkway E. Suite 121, Houston, TX 77060
Chicago, IL - 219 West Chicago Avenue, Suite 200, Chicago, IL 60654
How did you hear about us?
*
Word of Mouth
Instagram
Facebook
Linkedin
TikTok
Google Search
Outreach or Marketing Event
Social Service Organization or Nonprofit
Billboard
Website
School
Court System or Probation Officer
Other
What is your primary language?
English
Spanish
Which Family Solutions USA staff assisted or referred you to our program?
*
Please list their full name and office location.
Next Steps with Family Solutions
Submitting a referral only
I'd like to schedule an appointment now
Which of these weekdays works best for your intake appointment?
Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
Select one or multiple available timeslots for an intake appointment.
*
9:00 A.M.
10:00 A.M.
11:00 A.M.
12:00 P.M.
1:00 P.M.
2:00 P.M.
3:00 P.M.
4:00 P.M.
5:00 P.M.
6:00 P.M.
7:00 P.M.
Where would you like your appointment to take place?
*
Please Select
At the office
Virtually
At your home
Submit
Should be Empty: