Bexar County Community-Based Services Referral Form

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ARPA Grant

Services Requested (check all that apply) *

Case Management

Family Therapy

Youth Individual Therapy

Required

Referring Agency Name *

Name and Title
*

Phone Number: *

Email Address: *

Date of Referral: *

YYYY

Caregiver Full Name: *

Caregiver Date of Birth *

YYYY

Caregiver Gender *

Male

Female

Non-Binary

Caregiver Ethnicity / Race: *

Relationship to client: *

Phone Number: *

Home Address: *

Preferred Language:

Caregiver Employment: *

Caregiver Education: *

HS Diploma

GED

Other:

Caregiver Military Status: *

Active Duty

Veteran

None

Household Income: *

$15,000 - $24,999

$25,000 - $34,999

$35,999 - $49,999

$50,000 - $74,999

$75,000 - $99,999

$100,000 - $149,999

$150,000 - $199,999

$200,000 and over

Youth Name: *

Youth Date of Birth: *

YYYY

Youth Gender: *

Male

Female

Non-Binary

Youth School: *

Youth Grade: *

IEP or 504: *

IEP

504 Plan

N/A

Prior counseling Services: *

Yes

If yes, when:

YYYY

Primary Concern/Reason for Referral: *

Anxiety

Depression

Trauma/PTSD

Substance Use

Relationship Issues

Stress Management

Behavioral Concerns

Grief/Loss

Self-Esteem Issues

Other:

Please provide a brief description: *

Immediate Needs (if any): *

Mental Health Diagnosis (if any): *

Previous Therapy or Counseling: *

Yes

If yes, where/with whom:

Current Medications: *

Yes

If yes, list medications, dosages, reason:

Substance Use Concerns: *

Yes

If yes, please describe

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