"*" indicates required fields Has the program been explained to the client and/or the parent/guardian prior to submitting this referral?* Yes No Please select which state you're making a referral in: Florida Georgia South Carolina Referring IndividualName* First Last Email Address* Phone Number*AgencyHow did you hear about the program?*Relationship to Client:*Referred ClientName* First Last Phone*Email Gender Male Female Date of Birth School (If applicable)Grade (If applicable)Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code County of Residence*Language Preference:Known Diagnosis:Therapy Preference In Home Virtual Office School Based (Laurens 56) Therapy options are dependent on client, location, and providers available. We can discuss preferences with the client or caregiver in the initial consultation.I am referring: A child/youth (Age 3-17) A family An individual (18+) Therapy options are dependent on client, location, and providers available. We can discuss preferences with the client or caregiver in the initial consultation.Family InformationParent/ Guardian 1 Name First Last Parent/ Guardian 2 Name First Last Parent/Guardian PhoneParent/ Guardian Email Please list any legal guardians residing in the home:Please list any legal guardians NOT residing in the home:Please list any children or other household members residing in the home:Is anyone in the home a member of, eligible as a member of, or a biological child of a member of a Native American or Alaskan Indian tribe? Yes No Unknown If yes, name the tribe:Reason for ReferralAre there any other professionals working with the client or family? (i.e. pediatrician, school counselor, psychologist, psychiatrist, etc.):*Please discuss the reason the client is being referred:*What changes do you hope to see for this client and/or family?*
