REFERRAL FORM

Referred for:
Referred by: *
Referred by:
Telephone # *
Telephone #
Date *
Date
Full Legal Name: *
Full Legal Name:
Preferred Name:
Preferred Name:
Date of Birth: *
Date of Birth:
Address: *
Address:
Home Telephone #:
Home Telephone #:
Work Telephone #:
Work Telephone #:
Cellphone #:
Cellphone #:
Guardian Name (if person being referred is under 18 years of age):
Guardian Name (if person being referred is under 18 years of age):
Telephone #:
Telephone #:
Insurance Information - Please provide a copy of front and back of Insurance Card
Providers Currently Used
Symptom Checklist
Youth Name:
Youth Name:
Date
Date
Check reported symptoms (over the last 90 days):
Previous diagnosis
Complain of aches or pains
Spending excessive amount of time alone
Less interested in things used to like to do
Feelings of sadness, unhappiness
Feelings of hopelessness
Have trouble sleeping
Feeling tired or low energy
Feeling bad about self
Thoughts of hurting self
Thoughts of hurting others
Unable to sit still/acts if driven by motor
Have trouble following instructions
Distracted easily/have trouble concentrating
Racing thoughts
Loose things easily/unorganized
Forgetful of daily activities
Teases others/refuses to share
Quick change in moods
Fighting with others verbally
Fighting with others physically
Yelling, screaming, cursing
Throwing things or destruction of property
Often loses temper/easily irritated
Not attending school/refusal to go to school
Suspension/Expulsion
Detention/ISS
Grades have dropped
Change in behavior
Change in friends
Taking risks
Not listen to or follow rules
Stealing
Lying
Use of tobacco, alcohol, drugs
Risky sexual behavior
Argues with authority figures
Blames others for mistakes
Defies or refuses to comply with requests made by authority figures
Bully others
Physically cruel to animals
Fire setting
Illegal behaviors (with or without trouble with the law)
Run away from home or staying out past curfew
Worry a lot/nervous/anxious
Witnessed/experienced abuse
Youth should have at least 5 criteria met