Confidential Psychotherapy Referral Form

Just fill out this form and we'll contact your client to provide psychotherapy services, including enrollment in our psychotherapeutic meditation nature trips for teens in foster care. We appreciate your referral.

We keep all information confidential, and we use strong encryption to ensure all information is safe and secure.

If you prefer, you may print the following form and fax it to 510-878-7963:

Psychotherapy Referral Form

Please fill out as much information as you have, and include the client contact information.

Required fields have a red asterisk *

Client Information

* Client First Name

* Client Last Name

* DOB

* Social Security Number

* Street Address

* City

* State

* Client Phone

* Caregiver First Name

* Caregiver Last Name

CFS Information (If Known & Relevant)

CFS Worker First Name

CFS Worker Last Name

CFS ER Report #

CFS Worker Phone

CFS Worker Fax

CFS Worker Email

Crime, Abuse, & Neglect Information (If Known)

WIC 300 Allegations (If Relevant & Known) Serious Physical Harm
Neglect
Serious Emotional Damage
Sexual Abuse
Death of child
Abandonment
Termination of Parental Rights
Acts of Cruelty
Sibling Abused or Neglected

Attach Client Records (Optional)

Attach Copy of Legal History, ER Investigation Results, CWS/CMS Disposition Print Out, or Medical Records.

(Or Fax to 510-878-7369, ATTN:referral)

* Type of Crime

Approximate Date Crime Occurred (if known)

Approximate Date Reported to CFS/Law Enforcement (if known)

Additional information or Special Requests

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