Phone: (304) 941-6256 Fax: (304) 553-0379 Provider #: 0030217852

300 Kenton Dr, Suite 3, Charleston, WV 25311

REFERRAL

Referrer Info
Referral date:	Referred by:
Phone #:	Relationship to client:

Client Info
Client Name:	Phone #:
Address:	County:
DOB:	Age:	Gender:
Email:	SSN:
School:	Grade:

Who does client live with?
Why is client being referred?

Presenting Problems (check all that apply): ☐ Behavior problems ☐ Truancy ☐ Anxiety ☐ Depression ☐ Self-harm ☐ Parent-child conflict ☐ Violence/aggression ☐ Drug use ☐ Other:

Requested Services
☐ Psychological Evaluation	☐ In-person
☐ Individual Therapy	☐ Telehealth/virtual
☐ Family Therapy	☐ Either
☐ Other:
Legal Info
Client’s Legal Guardian(s):	Phone #:

For youth not in their parents’ custody:

Parent Name:	Phone:	Email:
Parent Name:	Phone:	Email:

Open CPS case? - ☐ Yes ☐ No	Open YS case? - ☐ Yes ☐ No

Court involvement? - ☐ Yes ☐ No	Next court date:

If yes, then please list charges:

Insurance Info
Insurance Name:	Member ID#:
Policy Holder’s Name:	DOB:

☐ Private Pay