Referral Form

Referral Source

Name of Person Making Referral

Relationship to Client

Phone number

Email*

Agency / Institution Name (If Any):

Seeking Therapy*

In-Office Outpatient Therapy

In-Home Behavioral Services for Kids

Online Telehealth Therapy

Preferred True family services texas Office Location*

Referral Source

Date of Referral*

Time of Referral

Client Personal Information

Client Name

Client Date of Birth

Does the client have Insurance?

Yes

No

If yes, Name of Insurance

If yes, Policy number

Does the client have a guardian?

Yes

No

Psychiatric History*

Medical History*

Are you having an emergency at this time?*

No

Yes

Client Contact Information

Client Address

Guardian/Next of Kin

Guardian’s/Next of Kin’s Phone Number:

Presenting Problem or Need

Intellectual Developmental Delayed

Mental Health

Substance Abuse

If the client has a diagnosis, list that here

Briefly explain the client’s current problem or need and describe any pertinent past information we should know:

Current:

Past:

Are you having an emergency at this time?

No

Yes

Emergency Contact

Name

Phone Number

Relationship

Referral Form

We’re Here to Help – Reach Out Today

Referral Source

Referral Source

Client Personal Information

Client Contact Information

Emergency Contact

Ready to start your mental health journey?