School Based Referral Form

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- Employment

School Based Referral Form

Client Information

Date of Referral(Required)

Client's Name(Required)

First Last

Date of Birth(Required)

Grade(Required)

Insurance Provider

Member ID

Medicaid(Required)

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

Interpreter Needed?(Required)

Yes

No

Language Spoken(Required)

Spanish

Mandarin

French

Thai

French Creole

Vietnamese

Hindi

Punjab

Arabic

Turkish

Bengali

Pashto

Urdu

Other

Client School(Required)

District(Required)

APS

Fulton

Forsyth

Henry

Clayton

Others

Referral From(Required)

Social Worker

School Counselor

Parents/Guardian

Hospital

DFCS

Juvenile Court

Others

Referral Contact(Required)

Phone(Required)

Email(Required)

Please confirm you have discussed services with the Legal Guardian prior to making this referral(Required)

Yes

No

Legal Guardian Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Parent/Guardian Email(Required)

Does client reside in Georgia?(Required)

Yes

No

Client diagnosed with Autism Spectrum Disorder?(Required)

Yes

No

Is the client verbal?(Required)

Yes

No

Has the client been hospitalized in the the past 6 months?(Required)

Yes

No

If yes, how many 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 Issues

Presenting 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

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.