Getting Help with Therapy

Your Full Name

Title, Role, Agency, and Contact Info (if applicable)

Your Email Address

Your Phone Number

What is Your Relationship to the Person You are Referring?

May We Leave You a Message on Your Phone? May We Leave You a Message on Your Phone? Yes No

Name of Referral

Age of the Person You Are Referring

Insurance Name

Insurance Number

Reason for Therapy, Concerns, Presenting Symptoms, Things You Want Addressed in Therapy

What Type(s) of Therapy Are You Requesting? What Type(s) of Therapy Are You Requesting? Individual Therapy Couples Therapy Family Therapy Parent-Child Interaction Therapy (PCIT) Parent-Child Attunement Therapy (PCAT) Not Sure Other

Is the Individual, Child or Family Currently Involved with Child Welfare Services? Is the Individual, Child or Family Currently Involved with Child Welfare Services? Yes No

Is Reunification Imminent? (Caregivers are about to be reunified with child and planned permanent placement is established) Is Reunification Imminent? (Caregivers are about to be reunified with child and planned permanent placement is established) Yes No Other

Does the Child Have More Than 1 Visit/Week with Caregiver(s)? Does the Child Have More Than 1 Visit/Week with Caregiver(s)? Yes No

Name of Caregiver(s) for Child to Participate in PCIT/PCAT

Phone Number of Caregiver(s)

Email of Caregiver(s)

May We Leave a Message on the Caregiver(s) Phone? May We Leave a Message on the Caregiver(s) Phone? Yes No

Additional Questions or Concerns