South Carolina Referral Form
ALL INFORMATION SUBMITTED IS CONFIDENTIAL
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
Client name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Client phone number
-
Area Code
Phone Number
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.)
School
Grade
Insurance Provider
*
Please Select
Healthy Blue (SC Medicaid)
Absolute Total Care (SC Medicaid)
Molina Healthcare (SC Medicaid)
Human Healthy Horizons (SC Medicaid)
First Choice (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
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
Parent/Guardian name, if applicable?
First Name
Last Name
Parent/Guardian phone number, if applicable?
-
Area Code
Phone Number
Parent/Guardian Email Address
example@example.com
Program Requested (select all that apply)
Outpatient Counseling
Multisystemic Therapy (MST), 10-18 years of age
Functional Family Therapy (FFT), 11-19 years of age
I'm not sure
Upload Supporting Documents (if applicable)
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of
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
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