NHBC Outpatient Referral Form by 8cKEpz8


									               Main Address: 101 Devant St., Ste. 702, Fayetteville, GA 30214
             Satellite Address: 2245 Godby Rd., Ste. 107 College Park, GA 30349
                          Phone-(770) 460-0970 Fax (866) 758-5731

                                Outpatient Referral Form
Referral Source (circle one):

   School     DJJ       Juv. Court   Other (please specify) ________________
County: __________________________ Date of referral: ________________________
Person Making Referral: ________________________ Telephone number: _______________

   Individual Therapy      Family Therapy      Other Services_______________________

Client/Child’s name: ________________________________________________________
Address: ________________________________________________________________
City: ___________________            Zip: _________________
Phone: __________________________
Social Security No: ____________________ (required) DOB: ______________
Gender:     Male     Female Race: ______________

Medicaid/Peachcare:         Yes    No       M/P number: _________________________
(If the family does not have Medicaid number, please indicate source of payment for services),
Some county cases with no Medicaid on a sliding scale fee.

Insurance: ____________________________ Insurance number: ___________________

Child’s school: ______________________________________________Grade: _________

Child lives with: Mother Father    Both Parents Maternal Grandparents
  Paternal Grandparents Legal Guardian: Name____________________________

Is client/child on medications?
   No         Yes    If yes, please list:_______________________________________

Most recent DSM IV diagnosis (required DSM codes with description and attach current
evaluation): Axis I______ Axis II______ Axis III______ Axis IV______ Axis V_____

Why is the client/child being referred to the program?
  Oppositional      Run Away        Drug Use      Depression    Truancy
  Sexual Abuse       Physical Abuse     Mental Health Issues    Sexual Perpetrator
  DFACS Involvement         Probation Violation    ADHD      Other: _______________

What outcome would you like to see for his/her participation? ______________________
Name of Case Worker/Probation Officer:

Phone: ___________________ Fax: ________________________
Email: _____________________________ (we will email you weekly updates on the case)

 Only for NHBC use          Case was assigned to: TH_________________________
 TA1 _____________________ TA2 ____________________ TA3 ___________________

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