Child’s Name
Date of Birth
Gender
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Male
Female
SSN
Amerigroup ID Number
Name of parent or guardian
Relationship to Child
Contact Phone
Alt. Contact Phone
Address
Name of child’s school
DFCS involvement?
Reason for counseling referral
ICD 10 Diagnosis
Please email or fax confirmed diagnosis to: office@familymenders.org or 423.266.3151
Current medication(s) and prescriber's name
Has child received individual therapy recently?
Yes
No
Name of Provider
Date of Service
Has this child been placed in a PRTF
Yes
No
PRTF Name
Date of PRTF
Mental health crisis stabilization hospitalization/mental health community service history
Which if the following symptoms does the Patient display? (Check all that apply)
Suicidal
Physically Self-Destructive
Legal Issues
Homicidal
Specialized School Placement
Substance Abuse
Sexually Aggressive
Foster Home
Psychotic
Physically Aggressive
Multiple Foster Homes
Serious Runaway Behavior
History of Significant Psychological Trauma
Severe Somatization
Other
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Justification and Circumstances for Requested Additional Services (Include Meds)
Number of Family Members in Household
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1
2
3
4
5
Name
Date of Birth
Relationship to Child
Gender
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Male
Female
Name
Date of Birth
Relationship to Child
Gender
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Male
Female
Name
Date of Birth
Relationship to Child
Gender
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Male
Female
Name
Date of Birth
Relationship to Child
Gender
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Male
Female
Name
Date of Birth
Relationship to Child
Gender
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Male
Female
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