INTERPROFESSIONAL CENTER FOR COUNSELING & LIFE SKILLS SERVICES
COUNSELING SERVICES REFERRAL FORM
Fax completed form to 651-800-4815 ∙ If questions, call 651-800-4820
PERSON CALLING:
RELATIONSHIP TO CLIENT:
AGENCY:
CLIENT NAME:
ADDRESS:
CITY:
PHONE:
___________
STATE:
Age:
Sex: M / F
Primary Phone:
Secondary Phone:
E-mail :
Insurance Y / N
ZIP:
Date of Birth:
Relationship Status:
Okay to call? Y / N
Okay to call? Y / N
Okay to receive
e-mails?
Y/N
Type:
If calling on behalf of child
please let us know who the
child lives with
_______________________
PRESENTING PROBLEM:
(Programs,
____________________________________________________________________

check all that apply)
Individual Therapy
Family Therapy
Couples Therapy
Group Therapy
Psychological Testing
Case Management/Other
________________________
_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________
_________________________________________________________
_________________________________________________________
Primary Language Spoken:
_________________________________________________________
____________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Problem
List (CHECK ALL THAT APPLY)
_________________________________________________________
Depression or mood changes  Relationship Problems
 Personality changes
 Low Self-esteem
______
 Suicidal
 Family problems
 Alcohol
 Grief/loss
 Major Mental Illness
 Self Harm
 Drugs
 Housing issues
 Poor supports
 Anxiety
 Chronic relapse
 Other
 School problems
 Legal Issues
 Disordered eating
_________________
 Work Problems
 Withdrawal
 Anger
CLIENT’S RELEASE
By signing below, I authorize the Interprofessional Center for Counseling and Life Skills Services to acknowledge
my enrollment in the program. Subsequent contacts with the referral source will require additional releases.
Name
For official use only
Intake Date:
___
___________
Intake Completed By: ________________________
Date & Time of 1st Appt._______________
Therapist Assigned: __________________________
Date
Communication and Follow-Up
Date of Contact
Initials
Notes/Status