Wraparound Services Referral Form

Service Requested

County

Is the person making the referral a parent or client?

If other, please provide your relationship

Referral Source Information

Name of person making referral(Required)

First Last

Referral Source Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referral Source Phone(Required)

Referral Source Email(Required)

Client/Family Information:

Name of child or teen(Required)

First Last

Age of child or teen(Required)

Gender

Language

English

Spanish

Creole

Other

Medicaid number, if known

Name of insurance company, if applicable

Client/Family Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Client/Family Phone(Required)

Client/Family Email(Required)

Check here if client is enrolled in school

Who has authority to consent to treatment for minor child?

Name

First Last

Relationship to child:

Client's Presenting Issues:

Currently taking psychotropic medications?

Yes

No

Referral reason(Required)

Check here if this is an urgent need

Does the client have a history of mental health issues/substance abuse?

Yes

No

Currently receiving other services?

Yes

No

Wraparound Services Update

Service Requested

Referral Source Information

Client/Family Information:

Who has authority to consent to treatment for minor child?

Client's Presenting Issues: