Building Families Personal Referral Form - Child/Teen Name of Parent/Guardian(Required) First Last Name of Child(Required) First Last Child's Date of Birth(Required) Month Day Year Best Phone Number(Required)Email(Required) Thornwell Email Updates Consent(Required) I would like to receive updates from Thornwell.By checking this box, you are agreeing to receive email updates from Thornwell's Building Families Program. Your information will remain private and used only for informational purposes on your behalf.Therapy Preference(Required) In Home Virtual In Office School Based (Laurens 56) Therapy options are dependent on age of the child, your location, and providers available. We can discuss your preferences in your free consultation.I am interested in therapy for:(Required) My child/teen My family Myself as the caregiver Therapy options are dependent on age of the child, your location, and providers available. We can discuss your preferences in your free consultation.Zip code where you and your child reside:(Required)County where you and your child reside:(Required)What goals/needs do you have for your family at this time? (check as many boxes as apply)(Required) Help with behavioral issues Help with school related concerns Foster Care/Adoption related issues Family going through a big adjustment Family going through loss/grief Help with parenting skills Help with co-parenting/blended family issues Other How did you hear about the Building Families program?(Required) Doctor School A family who participated in the program Another professional involved with my family (Mental Health Counselor, Occupational Therapist, Speech Therapist, etc) Social Media Online search for help Other Name of Referral Source
