Acknowledgements:

* = required

By test checking the box below, you acknowledge that you have read these terms, understand and agree to these terms. Project Family will not provide prescriptions for the medications listed here: Benzodiazapines and/or Psychostimulants for Adults. Project Family also does not determine and/or provide treatment for the services listed here: Workman's Comp Claims, Disability Determination, nor Recommendations Regarding Custody: *

By clicking here, I acknowledge and understand the above

For any minor child, the legal guardian/representative must be present at any initial evaluation appointment.

By clicking here, I acknowledge and understand the above

Client Information

First Name*

Last Name*

Date of Birth*

Social Security Number*

Under 18?*

Yes

Gender

Male

Female

Race*

Does Client or Guardian need an Interpreter?*

Yes

Address

Client/Placement's Phone #*

Client/Placement's Alternative Phone #

Address*

City*

State*

Zip*

Name of Placement/Point of Contact:

Relationship of Placement/Point of Contact to Client:

Insurance Information

Insurance Policy #, and Group # (Use 12 digit Medicaid # for Medicaid or CMO insurance) *

Service Request

Provide a brief background, and an explanation of why these services are being requested: *

Has the referred client ever received outpatient mental health treatment?*

Yes

Has the referred client ever received inpatient mental health treatment?*

Yes

Has the referred client ever taken any psychiatric or mental health medications?*

Yes

Has client received services from Project Family?*

Yes

Are any members of your family currently engaged in services with Project Family?*

Yes

Services Requested (please select all the services being requested for this client): Please note, to ensure continuity of care, our psychiatric services must be accompanied by therapeutic services provided within our agency.

Referral Source Information:

Is this a self-referral?

Yes