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Referral Form for Mental Health Services
Client Information
Name
Date of Birth
Gender
Male
Female
Couple
School & Grade
Services Requested
Office-Based Outpatient
School Based
Home/Community Based
Contact Number
Is it ok to leave a message?
Yes
No
Address
For Children & Adolescents - Parent or Legal Guardian Information
Name of Parent or Legal Guardian
Address
Contact Numbers
Current Living Situation
Home
Group Home
Foster Home
Psychiatric hospital
Other
Referral Source Information
Complete this section so we can contact you after the referral is made.
Name
Mailing Address
Phone
E-mail Address
How did you hear about The Village Life Center?
Child/Adult Mental Health Information
Known Current medication & dosage
Current DSM-IV Diagnosis
Reason for referral for treatment
In your own words, describe the child/adult in need for mental health services.
Please describe specific behaviors the child/adult is exhibiting.
Known Current Mental Health Symptoms
Check all that apply.
Hallucinations (describe below)
Delusions
Thought disorder
Bizarre (psychotic) behavior (describe below)
Anxiety/nervousness
Obsessive/compulsive
Phobias/fears
Depressed mood
Mood swings
Sleep disturbance
Irritability
Anger/temper tantrums
Hyperactivity
Attention deficit
Eating problems
Elimination problems
Oppositional/defiant to those in authority
Antisocial/delinquent behavior/conduct disorder
Over sexualized behavior
Somatic complaints with no known medical cause
Attachment disorder (explain below)
Other
Describe
Please enter the characters you see in the box below.
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