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- Employment

employee portal

Home
About Us
Services
Referrals
Group Sign Up
Consumer Feedback
Resources
Contact Us
- Employment

School based and County/DFCS referrals may either:

Download the fillable pdf form
Print
Email completed form to referrals@familytiesinc.com

Or select your referral type, complete, and submit the form below.

Note to successfully submit this form you must complete every field marked required. Please use the format that is described below each field to ensure successful submission. Upon completion you should see a success page with this sentence "Your responses were successfully submitted. Thank you!" If you do not see this, your entries have NOT been submitted.

Downloadable Forms

Forma De Referencia Escolar

1 file(s) 255 KB

Download

County/DFCS Referral

1 file(s) 154 KB

Download

School Based Referral Form

1 file(s) 396 KB

Download

Referral Type:(Required)

School based

County/DFCS

Self

Date:(Required)

MM slash DD slash YYYY

MM/DD/YYYY format only.

Has the parent or guardian been contacted prior to the submission of this form?

If this is a school system referral the parent or guardian MUST be contacted before submitting this form.

Yes

Referral Source

Organization/Agency(Required)

Name of referring person:(Required)

First Last

Title:

Email Address:(Required)

Must be in name@example.com format

Phone Number:(Required)

Enter area code and phone number with no spaces, dashes, or parenthesis example 4041239876

Mobile Number:

Fax Number

Preferred Contact Method:

Supervisor Name:

First Last

Supervisor Phone Number:

Is client aware referral is being made?

Yes

Client Information

Client's Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

County of Residence:(Required)

Medicaid or Private Insurance(Required)

Medicaid

Private Insurance

Current Insurance Information

Medicaid#

Gender(Required)

Male

Female

Race(Required)

Asian/Pacific Islander

Native American/American Indian

Black

White

Biracial

Other

Hispanic/Latin American(Required)

Yes

Client's School:(Required)

Current Grade Level:(Required)

School Contact(Required)

First Last

Phone(Required)

Email(Required)

Current Placement:

Social Security Number

Primary Insurance Carrier:(Required)

Medicaid

Amerigroup

Wellcare

Cenpatico

CareSource

Other

Name of Insurer:

*Required if "Other" is selected above.

Policy Number:

Separate multiple entries with a comma.

Previous Counseling Services:

Yes

Name of agency:

Date of Last services:

Less than 6 months ago

Greater than 6 months ago, but less than a year ago

Greater than 1 year ago, but less than 2 years ago

Greater than 2 years ago

Mental Health Diagnosis:

Medication(s):

Has client had a *psychiatric evaluation in the past 12 months?

Yes

Unknown

Has client had a *psychological evaluation in the past 12 months?

Yes

Unknown

Client's behavior over last 6 months:

Runaway

Physical Aggression

Suicidal Ideation/Attempt

Verbal Aggression

Defiance

Other

Brief Description of Presenting Issues:(Required)

Parent/Guardian Information Section

Parent/Guardian name:(Required)

First Last

Current Address:(Required)

Street Address City State ZIP Code

Email Address:

Must be in name@example.com format

Phone Number:(Required)

Legal Section

Is client involved in an open or pending court case?

Yes

Unknown

Current Probation Status:(Required)

Probation

Not on Probation

Probation Officer Name:

Probation Officer Phone Number:

DFCS case/Involvement:(Required)

Yes

Case Worker Name:

First Last

Case Worker Phone Number:

* If client is in the custody of DFCS, please complete this consent form. Type the correct information in the parenthesis.

Please attach any psychological/psychiatric or other supporting documentation.

Max. file size: 256 MB.

Electronic Signature(Required)

Family Ties, Inc. has been awarded the highest level of accreditation by CARF International for its Child and Adolescent Mental Health Services.

Family Ties, Inc. is an approved provider with Project Intersect – therapy for commercially sexually exploited children.