Referral – Universal Therapeutic Serivces, LLC

Referral's Name:

Referral's Agency:

Referral's Street:

Referral's City:

Referral's State:

Referral's Zip:

Referral's Position:

Referral's Email:

Referral's Phone Number:

Referral's Alternate Number:

Referral's Fax Number:

Client's Legal Name (First):

Client's Legal Name (Last):

Client's Birth Date:

Client's Race:

Client's Gender:

Client's Current Address:

Client's City:

Client's State:

Client's Zip:

Client's School (if applicable):

Is this an alternative school:

Client's Current Grade Level:

Approximate # days absent within the past 90 days:

Has client ever: (Check ALL that apply):

Been identified in the past to have a mental health, DSM-IV, diagnosis?
Expressed ideations of attempted suicide or homicide in the past?
Committed acts of physical or verbal aggression against a parent, teacher, or peer?

Is client a legal citizen of the United States?

Yes
No
Unknown

(This helps us to determine available benefits to clients in need)

How many people live in current household:

Total Monthly Household income:

Is client currently employed?

How many hours per week?

Is client currently using substances:

If so, what type:

Does client have a history of substance use:

If so, what type:

List current medications:

List past medications:

Is client English proficient:

Yes
No
Unknown

Does client or family need translation:

Yes
No
Unkown

If so, what language:

Parent/Guardian First Name:

Parent/Guardian Last Name:

Parent/Guardian Street Address:

Parent/Guardian City:

Parent/Guardian State:

Parent/Guardian Zip:

Relationship to client:

Parent/Guardian Email:

Parent/Guardian Home Phone:

Parent/Guardian Cell Phone:

Parent/Guardian Work Phone:

Alternate Person Contact Name:

Alternate Person Contact Number:

Is client currently insured:

Do you currently have Medicaid/HMO Insurance:

If Yes, provide Medicaid/HMO ID number:

If No, has client had Medicaid/HMO in the past 6 months:

Also state the reason that the Medicaid/HMO insurance is no longer active:

Do you currently have Private/Commercial Insurance (BC/BS, Aetna, etc.):

If Yes, List the Carrier Name:

ID number:

Customer Service Telephone Number:

If No, have you had Private Insurance in the past 6 months:

Also state the reason that the private insurance is no longer active:

REASON you are requesting Universal Therapeutic Services, LLC (Describe the problem(s):

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REFERRAL INFORMATION