Community Therapy Referral

Type of Therapy *
FamilyIndividualFamily & Individual

Preferred location *
In-personVirtualNo preference

Caregiver is aware of the referral
YesNo

Last Name *

First Name *

Middle Initial *

Date of Birth *

Age *

Preferred Contact Methods *
Home/CellEmailCallTextCan Leave a Message

Phone: (for Minor see Guardian Information below) *

Email: (for Minor see Guardian Information below) *

Address *

City *

Zip Code *

Language Preference

Gender/Gender Identity

Religion

Race

Ethnicity

Payment Method *
Self PayInsuranceOther

Other Payment Method

Insurance Provider: (Write Self Pay if no insurance) *

Insurance Group ID: (Write Self Pay if no insurance) *

Insurance ID: (Write Self Pay if no insurance) *

Legal Guardian *
Adult - Own GuardianTwo Biological ParentsTwo Adoptive ParentsBiological Mother OnlyBiological Father OnlyOne Biological Parent and One Step ParentFoster Parent(s)Adoptive Father onlyAdoptive Mother onlyAuntUncleSiblingCousinGrandmotherGrandfatherChildren's DivisionOther

Legal Guardian Name(s): (N/A for Adults) *

Home/Cell # *

Email *

Preferred Contact Methods (check all that apply)*
Home/CellEmailCallTextCan leave a Message

Court Ordered
YesNo

Referral Source: (Self for Adults)*

Relationship to Person Referred*

Phone Number *

Email *

Is the person being referred enrolled with any other Cornerstones of Care programs? If so, which one? *
Not EnrolledTreatment Foster Care (TFC)Intensive In-Home Services (IIS) / Intensive Family Reunification Services (IFRS)PathwaysFoster CareOther

Other Cornerstones of Care Program(s)

Type of Placement
Foster CareTPRAdoptionOther

Time(s) and Day(s) available for therapy sessions *

Reason for Referral: Briefly explain losses, trauma, abuse history, and safety concerns. List behavioral, emotional, and social concerns, hospitilizations, school-related difficulty, and presence of suicidal/ideations.*
AdoptionAggression/ AngerAnxietyCoping with changeDepressionFoster CareGrief/LossSchool AggressionSchool SuspensionsSocial SkillsSuicide Ideation/AttemptTrauma- Abuse/Neglect/Physical/EmotionalOther

Additional Reasons for Referral *

Previous or Current Diagnosis, if any

Current Medications

List your desired goals and outcomes of therapy *

Other Pertinent information (I.e. Specify the type of therapy recommended, preferences, and specific requests)