Family Resource and Development Center, LLC

A Partnership Toward Change...
FRDC Referral Submission Form

 
Today's Date:
Name of Referral Source:
Referral Source Telephone Number:
Name of Client:
Client's Date of Birth:
Client's Address:
Client's Telephone Numbers (Home, Cell, Work):
Name(s) of Parent(s) or Guardian(s):
Names and Ages of Siblings:
Reason for Referral:
Requested Service(s):  Individual Therapy
  Family Therapy
  Social Skills Group
 Age 5-8
  Social Skills Goup
Age 9-12
  Social Skills Group
 Age 12-14
  Teen Grief/Loss Group
  Teen Issues Group
Age 16-18
  Sibling Support Group
  Teen Issues Group
 Age 14-16
  Teen Eating Disorders Group
  Parent Support Group
Current School and Grade Level:
Special Education Services and IEP?:
Pediatrician:
Psychiatrist:
Psychiatric Diagnosis (ie. Depression, Anxiety, Bipolar, ADHD, Eating Disorder, PTSD, Autism, Asperger's):
Substance Abuse? (Please indicate
drug(s) of choice):
History of Suicidal Thoughts or Self Injury:
History of Threatening Behavior Toward Peers or Family:
Current Medications:
Past Medications:
Current Medical Problems:
Family History of Mental Illness or Psychological Stress:
Previous Mental Health Treatment (indicate date(s) of treatment, provider's name, facility name, etc.):
Desired Outcome of Treatment:
Desired Method of Payment for Services:  Self-Pay
Health Insurance
 Health Insurance Plan:
If Looking for a Specific FRDC Therapist, Please Identify: Geoff Genser, LCSW
Daniel Weiner, LPC
Marc Lehman, LMFT
 
 
 
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