Intake/Referral Form

M. Graham & Associates, Inc. 445 E.G. Miles Parkway, Suite 108 Hinesville, Georgia 31313 Office: (912) 877-7928 * Fax: (614) 388-3712

Intake/Referral Form Please Fax Intake/Referral Form to (614) 388-3712

Date of Referral: ______Consumer Information: Consumer Name: ______Medicaid/Peach care#______Date of Birth: ______Age: _____ SS#______Grade Level_ Gender: (Please Check) Male Female Race: ______Consumer’s Address: ______City______State ______Zip ______Home Phone#: ______Cell #: ______Work #: ______What Other Services Sought: 1. Has the Consumer had other services (e.g. Community Support Individual-CSI, Individual and /or Family Counseling)? Yes No Not Sure 2. Does the Consumer have a know Serious Emotional Disturbance and/ or Substance Abuse issue/diagnosis? Yes or No Not Sure 3. Are Consumer and/or family issues in need of intensive, coordinated clinical and supportive intervention? Yes No 4. Is Consumer/or child at immediate risk of out of home placement or is currently in out of home placement and re-unification is imminent? Yes or No 5. Has Psychological/Psychiatric Evaluation been completed? Yes No If yes, please attach Admission Status (Please Print) Name & Title of Person making referral: ______Agency: ______Court Mandated? Yes or No County: ______Phone # of person making referral: ______Fax number: ______Service (s) Requested (Please Check) Intensive Family Intervention Behavior Aide Crisis Intervention CORE-Medicaid Program (Indiv/Family Therapy; CSI, Groups) Other ______

Presenting Problem: (List problem behaviors; include any medications for emotional and/ or behavior problems)

For Company Use Only: Receipt Date: ______Insurance Active Yes No Medicaid Plan: ______Assigned to: ______Date Assigned: ______Assessment Completion Date: ______Consumer Approved? Yes No If not approved, why? ______If approved, approval date? Ref#

“Healing One Family At A Time"