ࡱ> Z\YW Lbjbjff Nii  ::4NNNhDN+Z + + + + + + +$-00+-M0+::]+($($($F: +($ +($($:&),@)"uJ@R) *s+0+\)Rm1.m1)m1)HZA@($40+0+!t+m1 X :  Interprofessional Center for Counseling & Legal Services COUNSELING SERVICES REFERRAL FORM Fax completed form to 651-962-4815 " If questions, call 651-962-4820 REFERRAL SOURCE: RELATIONSHIP TO CLIENT: AGENCY: PHONE: CLIENT NAME: PREFERRED NAME: ADDRESS: CITY: STATE: ZIP: Age:Date of Birth:Gender:Marital Status:Preferred Pronouns:Significant other or partner?Y/NPrimary Phone:Okay to call? Y / NIf calling on behalf of child please let us know who the child lives with _______________________Secondary Phone:Okay to call? Y / NE-mail : Okay to receive e-mails? Y / NInsuranceY / NType:  Problem List (CHECK ALL THAT APPLY) Depression or mood changesRelationship ProblemsPersonality changesLow Self-esteemSuicidalFamily problemsAlcoholGrief/lossMajor Mental IllnessSelf HarmDrugsHousing issuesPoor supportsAnxietyChronic relapseOtherSchool problemsLegal IssuesDisordered eating_________________Work ProblemsWithdrawalAngerCLIENTS RELEASE  For official use only Referral Date: Referral Completed By: ________________________     (Programs, check all that apply) Individual Therapy Family Therapy Couples Therapy Case Management Psychological Testing CPT Career Counseling Primary Language Spoken: _______________________ Interpreter Required? Y/N Hospitalizations Suicidal Self-Injury Unstable/safe housing, food, relationships Disordered eating Substance Use Psychosis Obsessive Compulsive Disorder (OCD) PTSD Screening (ELIGIBILITY): Previous Diagnoses List: +Info: Presenting Problem (what do you want help with): By signing below, I authorize the rt  @ B ` b l n r        # + , - 2 7 = A Ⱦ~rk h()>*CJhZi&h()5>*CJhFLhFL5>*CJ hZi&5CJhZi&5>*CJhFL5>*CJh()5>*CJ h()5CJ hZi&5CJh$yh hD^JhDh(h"s h():CJ$ h()>* h"s>*h"sh()5:CJ h():CJ hG:CJ*tB r  - I J O P _ ` $$Ifa$$a$$a$gdY$$a$gdGgd"sA E H I J M O P ] _ ` a g i j y z { | $ % < = > H O P b d e f g h r s Ǽָڴڮڸڴڴڴڸڸh(h(CJ h()CJ h(CJh2+h bhchZi&CJaJhchcCJaJhchZi&h()h" h()CJ h()>*CJh()5>*CJ h()5CJ<` a i j ;/# $$Ifa$gd b $$Ifa$gdZi&kd$$Ifl\bn(    064 lapyt2+j z { | 2& $$Ifa$gdZi&kd$$Ifl\bn(     064 lapyt2+ $$Ifa$ $$Ifa$gdc $$Ifa$ $$Ifa$gd b ;2) $$Ifa$ $$Ifa$kd$$Ifl\bn(     064 lapyt2+ % = $$Ifa$gd( $$Ifa$gd2+= > O P 8/& $$Ifa$ $$Ifa$kd $$Ifl4y\bn(   `  064 laf4pyt2+P f g h #kd!$$Ifl4^\bn(      064 laf4pyt2+ $$Ifa$ $$Ifa$gd2+h r s $$Ifa$gd2+ $$Ifa$ $$Ifa$ 8/& $$Ifa$ $$Ifa$kdC$$Ifl4$\bn(      064 laf4pyt2+ /*$a$kde$$Ifl4L\bn(       064 laf4pyt2+ $$Ifa$ $$Ifa$gd b     / 0 @ A J Y Z a b l m n ҼҸzznjzznh&hTWUhD5OJQJ hAhD hhDhD h 'hDhY$h$y5OJQJhY$hY$CJaJ hY$6h$y5OJQJh2+jhKCJUmHnHu h()CJh()jh;hUmHnHujhKUmHnHujheUmHnHu)   0 @ & F$IfgdTWUgd$y $ a$gdH$ a$ $ h^ha$$ & Fa$$a$@ A J Z b H8++ & F$IfgdTWU$ & F$Ifa$gdTWUkdo$$Ifl\\ "+\    t0644 lalp(ytTWUb m n ;+$ & F$Ifa$gdTWUkd>$$Ifl\\ "+\    t0644 lalp(ytTWU & F$IfgdTWU     * + 0 1 2 3 C D E F G H I J K M N O ⿷}h2+CJOJQJaJh(CJOJQJaJ h()5CJ h()CJh() jh2+5>*UmHnHuh"shR5 h5 h$yhD h 'hDhuhTWUhD>*hDhTWUhD5OJQJ hAhDh& hhD+ ;+$ & F$Ifa$gdTWUkd $$Ifl\\ "+\    t0644 lalp(ytTWU & F$IfgdTWU ;kd $$Ifl\\ "+\    t0644 lalp(ytTWU & F$IfgdTWU  $Ifgdu & F$IfgdTWU$ & F$Ifa$gdTWU  + 1 H8++ & F$IfgdTWU$ & F$Ifa$gdTWUkd $$Ifl\\ "+\    t0644 lalp(ytTWU1 2 3 D F G ?:55$a$$a$kdz $$Ifl\\ "+\    t0644 lalp(ytTWU $IfgdDG H I K M N O e 04 & FgdZi& & F & Fgd:dhgd(gd(b]bO S d e m o t v w x y z  Ļճճ|sssmmmmm h:aJhuh"saJhuh()6aJhuh"s6aJh(h()6CJaJh6Hjh6HUhchR OJQJhDOJQJh)=>*OJQJh"s>*OJQJh(OJQJh"sOJQJh$OJQJh(CJOJQJaJh(h(CJOJQJaJ'  034EF_vw  +12678~zhh.hKhKCJ hKCJhh.hh.CJhFhh.CJaJhFhKCJaJhFhFCJaJhKhh.CJ hh.CJh()huhZi&aJhZi&hZi&aJ hZi&aJ h,baJ h)=aJhuh"saJhuh:aJ.4F_w2789Uipxy$a$gd;h hh^h`hgdK$a$gdK & FgdK & Fgdh.gd,b & FgdZi&89BCDJOPQRSTUV[ghinopqvwxҺ}}qhh_SMDhh.h7:CJ hh.CJhh.hh.6CJ]hc6CJ]hKh;hCJhKh;h6CJ] hKCJh;hh;hCJhKh()CJaJhKh bCJaJhKh b5CJaJhKh()5CJaJhKh7::CJaJhKh;h:CJaJhKh b:CJaJhKh b5:>*CJaJhKh;h5:>*CJaJhKxyLJLiLLLLLLLLLLLLhchR OJQJ h()>*Uh"sh;h h;h5hKh;h:CJaJh;h5:>*hKh;h5:>*CJaJh()LLLLLLLdhgd($a$$a$gd"sgd;h Interprofessional Center for Counseling and Legal Services to acknowledge my enrollment in the program. 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