Referral Form for a Child / Adolescent

230 North Limestone, Suite 100 Lexington, Kentucky 40507
(859) 303-8041 office@heatherriskandassociates.com

If you would like to refer a child or adolescent for an assessment or treatment, please complete the information below. This information will help Heather Risk PsyD & Associates, PLLC in ensuring your child's needs are met. After receiving the following information, we will contact you to discuss any questions and take the next steps to beginning services.

Today's Date:

What is the child's name?

Gender:

Female

Male

Other:

Date of Birth:

Age:

Current Grade:

Caregiver(s) / Legal Guardianship Contact Information

Please include complete accurate information - You may place an asterisk (*) next to preferred methods of contact.

Caregiver(s) / Legal Guardian(s):

Relationship to child:

Biological Parent(s)

Foster Parent(s)

Adoptive Parent(s)

Grandparent(s)

Other:

Address:

Home Phone:

May we leave a message at this contact?

Yes

Cell Phone:

May we leave a message at this contact?

Yes

Work Phone:

May we leave a message at this contact?

Yes

Email Address:

May we leave a message at this contact?

Yes

Is there a DCBS Worker/Child Welfare Worker working with this child or family?

Yes

If yes, DCBS Worker's Name:

(DCBS) Phone Number:

(DCBS) Email:

If no, has DCBS / Child Welfare worked with this child / family in the past?

Yes

Who has custody of this child, currently?

Has this child ever been in the custody of another caregiver?

Yes

If yes, please explain:

Who is completing this form? (Name)

Phone:

Email:

Relationship to child:

What type of service(s) are you seeking for this child?

Assessment

Treatment

Assessment and Treatment

Consultation

Other:

Why are you seeking an assessment and/or treatment for this child? Please be as specific as you can as you explain your concerns, when the concerns began, and your goals for services.

Has this child experienced any history of trauma, abuse, or maltreatment? If so, please explain the history.

Has this child ever made any suicide attempts or demonstrated violent behavior? If so, please describe (age, reasons, circumstances, behaviors, etc.)

Has this child received therapy in the past? If so, please provide a brief description of the services they received, reason for services, provider or agency name, and why services ended

Specify any medication the child is currently taking and for what:

Is there any additional information you think we should know before beginning services?

Do you have any questions?

Referral Form for a Child / Adolescent

Caregiver(s) / Legal Guardianship Contact Information

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