Counseling Referral

Please fill out this form, and someone from our office will be in contact with you. If you have any questions, you can reach us at counseling@seyfs.org, or call us at (206) 721-5542, ext. 31.

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Person making referral *

Relationship to client/agency *

Referral phone number *

Date of referral *

Name of prospective client *

DOB/age *

Address *

Zip Code *

Is client aware of referral? *

• Yes
• No

Does the person have Medicaid? *

• Yes
• No

Does the person have commercial insurance? *

• Yes
• No

Type of Commercial Insurance

Ethnicity *

Preferred language *

Gender Identity *

• Male
• Female
• Other

Please specify gender identity

Contact for client *

Guardian(s) *

Guardian's phone number *

Have guardians been notified? *

• Yes
• No

Okay to contact guardian? *

• Yes
• No

School youth attends *

Grade *

Emotional Issues

• Emotional Issues

Describe Emotional Issues

Family Problems

• Family Problems

Describe Family Problems

Behavioral Problems

• Anger Outbursts
• Defiant Behavior
• Violent/Aggressive Acts

Abuse Suspected

• Emotional
• Physical
• Sexual

Reported to CPS?

• Yes
• No

History of Mental Illness

• History of Mental Illness

Mental Illness Diagnosis

Suicide

• Ideation
• Threats
• Attempts
• Self Harm

Suicide Ideation Dates

Suicide Threat Dates

Suicide Attempt Dates

Self Harm Dates

Checkboxes

• Runaway

Prostitution Involvement

• Prostitution Involvement

Social Problems

• Rule-breaking
• Social Skills Deficit

School Problems

• Attendance
• Acting Out
• Peer Problems
• Teacher/Authority Issues
• Academic

Substance Abuse

• Youth
• Family

Legal Problems

• Probation
• Other

Describe Legal Problems

Pregnancy

• Pregnancy

Health Issues

• Health Issues

Describe Health Issues

youth Abuse Attempt

Additional Comments

Submit