Advantage Counseling Service

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ADVANTAGE COUNSELING SERVICE
	Username:
	Password:

Intensive Family Intervention
Program Referral

Referral Date:

Routing Information:
Office:
Services Provided:	In-Home Counseling 24-Hour Crisis Intervention Educational Advocacy and Support	Parent Skills Training Community Resource & Referral

Name of Child:
First: Last:
Date of Birth:

Education Information:
School Attending: Grade:
Is Child Receiving SST or Special Education? Yes No
If yes, please indicate which program:

Name of Parent:
First: Last:
Address: City: State: Zip:
Home Phone : Work Phone :

Referring Agency:
Agency Name:
Contact Person:
Phone:
Medicaid / Peach Care #:

Other Information:
Has Psychological Evaluation been completed? Yes No
(If yes, please fax referral.)
What are the behaviors currently displayed by child that are placing him/her at risk of out of home placement?

Is Child Court Involved? Yes No
(If applicable, please list court date, PO, etc.)