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Client Referral
Self Referral Form

Self Referral Form

Request for Services

If you or a loved one need services (therapy, SUD and/or community counseling support), please complete this form and someone will contact you.

"*" indicates required fields

If the required field is unknown, please enter 'N/A' or 'Not Applicable'.

Name of person completing referral*

Email of person completing referral*

Client Info

Client Name*

First Middle Last

Date of Birth:*

MM slash DD slash YYYY

Gender

SSN:

Race:*

Parent/Guardian Name

Phone Number

Insurance

At a minimum, please enter your primary insurance. If you have secondary insurance, please click the plus sign to the right of the fields to add your secondary insurance information.

Insurance Coverage Type (Medicaid, Medicare, Private Insurance, Uninsured)

Policy #

Address

Street Address & Apartment/Suite # City State ZIP Code

Client Phone:*

Client Email

Highest Grade Completed

Does the client give permission to be contacted via social media?

Yes

No

Social Media Contact Information

Social Media Platform

Username

Employment Status

Military Experience

Yes

No

Currently Pregnant:

Yes

No

Under Legal Guardianship

Yes

No

Reason for Referral:*

Check all that apply.

Arlington Grief & Loss Group

Abuse (Physical/Emotional/Sexual)

Academic/Educational Challenges

Behavior/Conduct Challenges

Emotional/Mental Illness

Legal (Custody or Incarceration)

Psychiatric/Med Mgmt

Physical Health Challenges

Relational Conflict

Social/Interpersonal Challenges

Substance Abuse

Housing Instability

Symptoms and Behaviors/Risk Behaviors:*

Check all that apply.

Anxiety/Panic

Abandonment/Attachment Problems

Depressed/Low Energy

Fire Settings/Pyromania

Homicidal/Suicidal Ideations

Hyperactive/Impulsive

Isolative/Loner

Lying/Manipulative

Manic/Obsessive/Compulsive Mood

Oppositional Defiant/Verbal Aggression

Physical Aggression/Property Destruction

Running Away/AWOL

Self-Care Deficit

Self-Injurious Behavior

Stealing/Theft

Trauma (Severe)

Truancy

Services Requested*

Check all that apply.

Alcohol/Drug use

Behavior Norms

Community Resource Access

Communication Skills

Coping Skills

Emotional Health Practices

Family Relationships

Financial Mgmt/Benefits Access

Healthy Social Networks

Housing Stablity/Maintenance

Leisure/Social Activities

Nutrition/Fitness

Personal Hygiene

Personal Safety

Problem-Solving

Productivity (Home/School/Work)

Sexuality

Time Management

Is the client currently receiving outpatient mental health therapy?*

Yes

No

Is the individual currently receiving Peer Support Services?

Yes

No

Name of Peer Support Provider and preferred contact:

Treating Therapist Name:

First Last

Therapist's Phone Number

Therapist's Email

Is the individual currently receiving Target Case Management Services?

Yes

No

Name of Target Case Management Provider and preferred contact:

Preferred Available Day(s) for Initial Appointment

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred Time of Initial Appointment

Morning

Afternoon

Evening

General Comments

Name

This field is for validation purposes and should be left unchanged.

WIN Family Health
2502 W. Northern Parkway
Baltimore, MD 21215

ph: (410) 578-8003

info@winfamilyservices.org

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