Make a Referral Mental Health Referral FormCORE ServicesName of Referring Person *FirstLastDate of Referral *County *Agency *DFCSDJJSchoolFamilyOtherPhone Number *Office/Home Phone Number Cell Phone *Fax NumberEmail *Preferred Contact Method *Home/Office Phone Cell Phone Email Case Manager NameFirstLastCase Manager Cell NumberSupervisor NameFirstLastSupervisor Phone NumberClient Name *FirstMiddleLastClient Age *Client DOBClient Date of Birth Client ID#(If Applicable)Gender *Female Male EthnicityClient's School Current Grade LevelCurrent Placement *Biological Placement Foster Home Group Home Other If other, please explain *Legal Guardian's Name *FirstLastCurrent Address Current Phone Number Client Mental Health Diagnosis *List All Mental Health DiagnosisMedications List All Medications Medicaid #Social Security #Name of Insurance ****Please Note*** Uninsured families must apply for PeachCare before services can be provided. For more info please visit PeachCare at www.peachcare.org.Has client had a Psychological Evaluation in the past 12 months?YesNo UnknownHas client had a Psychiatric Evaluation in the past 12 months?YesNoUnknownBehavior in the past 3-6 months:RunawayPhysical AggressionSuicidal Ideation/AttemptVerbal AggressionDefianceOtherPlease check all that apply.Please Explain **Other BehaviorsList ALL Behaviors In The Past 3-6 Months!Present Challenges/Problems *Please explain the client's present challenges/problems.Legal Involvement YesNoExplain Open/Pending Court Case *If yes, to legal involvement, when? Please explain open/pending court case. DFCS Involvement *YesNoDFCS Approval For ServicesYesNo*** If child is in the custody of DFCS, please complete consent form. Electronic Signature *FirstLastRequired Electronic Signature Date Signed *CommentSubmit Referral ***Please upload psychological and psychiatric evaluations: Psychological/Psychiatric Evaluation Upload files JSON parse warning!