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Winners Circle Group of Texas : Referral Form
Behavioral Mental Health Referral Form
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Email
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Your email
Which "Winners Circle Group of Texas" city is closest to the child being referred?
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Houston
Duncanville
Tyler
Midland
Beaumont
Other:
Name of person making the referral:
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Your answer
Date of referral:
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MM
/
DD
/
YYYY
Relationship to client & phone number:
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Your answer
Agency/Institution (if any):
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Your answer
Nature of referral:
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Emergency (less than 24hrs)
Urgent (24hrs)
Routine (7days)
Other:
Client's Name
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Your answer
Client's Date of Birth:
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MM
/
DD
/
YYYY
Client's insurance carrier and policy number:
Your answer
Foster parent/Caregiver/Legal Guardian Name, Phone Number, Email Address:
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Your answer
Client's full address:
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Your answer
Client's phone number:
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Your answer
Select all that apply.
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Intellectual Developmental Delay
Mental Health
Substance Abuse
Other:
Required
Briefly explain the client's diagnosis (if any) and pertinent past information we should know. (Abuse/neglect history, etc)
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Your answer
Please explain the client's current problems and behaviors that will require assistance and services:
Your answer
Emergency contact/Guardian/DFPS/SSCC (Name/phone number/relationship):
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Your answer
Send me a copy of my responses.
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