Client InformationDate of Referral(Required) Client's Name(Required) First Last Date of Birth(Required) Insurance Provider Member ID Medicaid Yes No Gender(Required) Male Female Other Race(Required) Asian/Pacific Islander Native American/American Indian Black White Biracial Other Hispanic/Latin American(Required) Yes No Client's School Grade Interpreter Needed?(Required) Yes No Language Spoken(Required) Spanish Mandarin French Thai French Creole Vietnamese Hindi Punjab Arabic Turkish Bengali Pashto Urdu Other Referral Source Contact(Required) Phone(Required)Email(Required) Referral Source(Required) DFCS School Hospital Other Please confirm you have discussed services with the Legal Guardian prior to making this referral(Required) Yes No Legal Guardian's Name(Required) First Last Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Parent/Guardian Email Does client reside in Georgia? Yes No Client diagnosed with Autism Spectrum Disorder?(Required) Yes No If yes, Is the client verbal?(Required) Yes No Has the client been hospitalized in the the past 6 months?(Required) Yes No If yes, # of times?(Required) In the last 3 months has the client had any suicidal thoughts?(Required) Yes No Suicide attempts?(Required) Yes No Is the client currently prescribed medication?(Required) Yes No Is the client interested in obtaining medication management services through Family Ties?(Required) Yes No Presenting IssuesPresenting Issues(Required) Anxiety Aggression Depression ADHD/ADD Suicidal Thoughts Self Harming Eating Disorder Foster Care Adjustment Issues Grief Trauma Substance Abuse Concerns Post Traumatic Stress Disorder (PTSD) Additional Concerns/Issues
