Make a Referral Is the individual you are referring 18 or over?* Yes No Important!!! Unfortunately, our office is no longer providing adult therapy services. We will continue seeing children, adolescents, and families. If you need adult, mental health, or substance abuse services, please go here.Today's Date* MM slash DD slash YYYY Name of Individual Being Referred* First Last Date of Birth* MM slash DD slash YYYY Guardian Name(s)*With whom does the client reside?* First Last Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Alternate PhoneEmail* Will you be utilizing insurance to pay for therapy services? If yes, what insurance(s)?*DCBS Involvement?* Yes No Case Worker First Last Is there an ongoing or upcoming custody/visitation issue or court case?* Yes No Judge's Name (Please write None if there is no Judge involved)*Reason For Referral*(please include any specific behavioral or emotional concerns)Services Requested Individual Therapy Group Therapy Family Therapy Mental Health Assessment Only Name of Person Making Referral* First Last How do you know the person being referred?* I'm Referring Myself I'm a Friend or Family Member I'm a professional working with this person Agency Phone*Email* Is Guardian aware of the referral and expecting a call?* Yes No If I am currently unable to take new clients--would you want to be added to a waitlist?* Yes No Our office only has one provide (C.J. Quick, LPCC-S, LMFT, RPT-S); however, there are two other therapists with agencies in the same office. If they are taking new clients and C.J. is not, would you want us to share this referral information with them? No, do not share the referral with them Yes, please share the referral with Beth Brown, LPCC-S, RPT-S (Better Beginnings Counseling) Yes, please share the referral with Sarah Reynolds, LCSW (Building Foundations Counseling and Consultation) Yes, please share the referral with Beth Brown and Sarah Reynolds Will you be faxing additional information to Brighter Futures Counseling in regards to this referral? Examples: Prevention Plan/Case Plan, EPO/DVO, Court Orders, Psychological Testing Report, etc. Our fax # is: 270-982-9293* Yes No