sbp-logo-transparent-blue logo
employee portal
  • Home
  • About Us
  • Services
    • Telemental Health
    • CORE
    • DFCS
    • Private Consulting
    • School Based Program
      • Services
      • School Based Trainings and Groups
      • School Partners
      • School Based Referral Form
      • SBP in the Community
  • Referrals
  • Group Sign Up
  • Consumer Feedback
  • Resources
  • Contact Us
    • Employment
employee portal
sbp-logo-transparent-blue logo

×
  • Home
  • About Us
  • Services
    • Telemental Health
    • CORE
    • DFCS
    • Private Consulting
    • School Based Program
      • Services
      • School Based Trainings and Groups
      • School Partners
      • School Based Referral Form
      • SBP in the Community
  • Referrals
  • Group Sign Up
  • Consumer Feedback
  • Resources
  • Contact Us
    • Employment

School Based Referral Form

Client Information

Client's Name(Required)
Medicaid
Gender(Required)
Race(Required)
Hispanic/Latin American(Required)
Interpreter Needed?(Required)
Language Spoken(Required)
District(Required)
Referral From(Required)
Please confirm you have discussed services with the Legal Guardian prior to making this referral(Required)
Legal Guardian Name(Required)
Address(Required)
Does client reside in Georgia?
Client diagnosed with Autism Spectrum Disorder?(Required)
Is the client verbal?(Required)
Has the client been hospitalized in the the past 6 months?(Required)
In the last 3 months has the client had any suicidal thoughts?(Required)
Suicide attempts?(Required)
Is the client currently prescribed medication?(Required)
Is the client interested in obtaining medication management services through Family Ties?(Required)

Presenting Issues

Presenting Issues(Required)
Family Ties Groups
CARF

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

Project Intersect

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

© 2018 Family Ties, Inc. | Website Design by Sumy Designs LLC