Referral Form
ALL INFORMATION SUBMITTED IS CONFIDENTIAL
Date
-
Month
-
Day
Year
Date
I am
*
Client
Parent or guardian
School personnel
DSS Staff
DJJ/Court Staff
Other
Person making the referral
First Name
Last Name
Referrer's phone number
-
Area Code
Phone Number
Referrer's contact email
example@example.com
Is the client in the custody of DSS?
Yes
No
Client name
*
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Age
Client phone number
-
Area Code
Phone Number
Grade
Please pick the state where the client resides
Please Select
Georgia
South Carolina
Please pick the region where the client resides
Please Select
Upstate (Greenville, Spartanburg, Anderson, etc.)
Midlands (Columbia metro, Aiken, Sumter, Orangeburg, etc.)
Pee Dee (Florence, Myrtle Beach, Georgetown, Darlington, etc.)
Lowcountry (Charleston, Beaufort, Hilton Head, Walterboro, etc.)
Please pick the region where the client resides
Please Select
Chatham County
Chattahoochee County
Cherokee County
Clayton County
Coweta County
DeKalb County
Fayette County
Fulton County
Hall County
Harris County
Heard County
Henry County
Macon-Bibb County
Marion County
Merriwether County
Muscogee County
Pike County
Rockdale County
Spalding County
Talbot County
Taylor County
Troup County
Client Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School
Insurance Provider
Please Select
Healthy Blue (SC Medicaid)
AmeriHealth Caritas (SC Medicaid)
Blue Cross Blue Shield (SC)
Peach State Health Plan (GA Medicaid)
CareSource (GA Medicaid)
WellCare (GA Medicaid)
Blue Cross Blue Shield (GA)
UnitedHealthcare (Commercial/Medicaid)
Cigna
Aetna
Other
No insurance
Insurance Number, if applicable
Has the family been contacted and is interested in learning more about the Grace Harbour services?
Yes
No
Reason for referral (select all that apply)
Difficulty focusing or paying attention
Declining grades or academic performance
Truancy or frequent absences
School adjustment or transition concerns
Defiance or oppositional behavior
Aggression or acting out
Impulsivity or hyperactivity
Risk-taking behaviors
Anxiety
Depression or sadness
Anger or irritability
Family conflict
Parent–child relationship issues
Peer or social difficulties
Bullying (victim or perpetrator)
Trauma or grief support
Substance use concerns
Crisis intervention or safety concerns
Other
Has the referral been staff and approved by your supervisor?
Yes
No
Parent/Guardian name, if applicable?
First Name
Last Name
Parent/Guardian phone number, if applicable?
-
Area Code
Phone Number
Youth will be under DJJ supervision for the next 100 days (FFT Referral) or 130 days (MST Referral)?
Yes
No
Where is the youth currently residing?
With Parent/Caregiver
Other Out-Of-Home Placement
Detention Center
Is the youth currently pending out of home placement within the next 45 days?
Yes
No
Will the youth be returning to reside with Parent/Caregiver in the next 10 days?
Yes
No
Program Requested (select all that apply)
Individual Counseling
Family Counseling
Group Counseling
Multisystemic Therapy (MST), 12-17 years of age
Functional Family Therapy (FFT), 11-18 years of age
I'm not sure
Program Requested (select all that apply)
Individual Counseling
Family Counseling
Group Counseling
Functional Family Therapy (FFT)
I'm not sure
Program Requested (select all that apply)
Individual Counseling
Family Counseling
Group Counseling
I'm not sure
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-
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