CLIENT
Client Name:		If Minor Legal Guardian/Parent(s) Name:
Age:		Grade:
		School:
Cell Phone:		Home Phone:
Work Phone:
Address LIne 1:		Address Line 2:
City:		State:
Zip Code:
Date of Birth:		Medicaid:	Yes​   No
AGENCY
Referral Source/Agency:		Referring Source/Agency's Address:
District:		Person Making Referral:
Phone Number:
Reason for Referral:
Desired Outcome(s) of Assessment /Treatment (Please Be Specific):
Please check all that apply: Emotionally Detached Drug Abuse Arguing Stealing Day Dreaming Criminal Legal Record Isolation From Peers Uses Profanity Physical/Domestic Violence Mood Swings Excessive Distractibility Socialization /Peer Conflicts Crying Difficulty Staying on Tasks Teacher/Student Conflicts Underachievement Excessive Laughter Delinquency Depressed Excessive Fidgeting Truancy Irritability Pushing Teen Pregnancy Frustration Punching Financial Hardship Anger Biting Runaway History Hostility Hitting Prostitution Family Conflict Divorce/Separation Enuresis (Involuntary Urination) Parenting Issues Suicidal Ideation Encopresis (Involuntary  Defecation) Child Abuse Past Suicide Attempts Unusual Food Behaviors Child Neglect Medical Illness/Disabilities Sexual Abuse/Incest Developmental Disabilities Alcohol Abuse Self-Harm​ Other     ​ In submitting this form, you are giving Valley-Wide permission to communicate with the referring agency regarding your attendance at your first scheduled appointment. This release regarding your first appointment will expire in 45 days. No further information may be released without a signed Authorization for Release of Information form.  Note:  Minors twelve years of age or older may consent for their own behavioral health treatment.  Minors 15 years of age or older may consent for their own substance abuse treatment.    Referrals must have signatures in order to be processed. Client Signature                                                                                                                            Person Authorized to Sign for Client                                      (Name & Authority)                         Submit Form:     Secure Internet Services    Or: