Counseling Referral Form

CHS Location(Required)

Type of service requested

In-school counseling

In-home counseling

In-office counseling

Telehealth counseling (Video sessions)

If in-school counseling is requested, please list the name of the school

Is the person making the referral a parent or client?

Name of Person Making Referral

First Last

Relationship/Agency

Contact Address

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email

Currently psychotropic medications?

Yes

No

Referral reason

Check here if this is an urgent need

Client mental health/substance abuse history

Yes

No

Currently receiving other services?

Yes

No

This field is hidden when viewing the form

If yes, what type and where?