Counseling Referral Form | The Parenting Place

Child Abuse and Neglect Prevention Agency Serving Greenville, Pickens, Anderson, Oconee and Spartanburg

1039 S. Pendleton St., Easley, SC 29642

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couseling services

Counseling and Supportive Services

couseling services

Counseling and Supportive Services

Counseling Referral Form

Demographic Information

Client Name*

First

Last

Select *

Adult

Minor

Date of Birth*

day

/

month

/

year

Age*

Gender*

Female

Male

Transgender M-F

Transgender F-M

Non-Binary

Other

Marital Status:*

Married

Single

Widowed

Divorced

Separated

Common Law

Living Together

Partners

Engaged

Ethnicity:*

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian

Common Law

Other Pacific Islander

White Non-Latino or Caucasian

Some Other Race

Client Address*

Street Address Apartment Complex and Apt # (if applicable) City State Postal / Zip Code

County:*

Client Email Address*

Client Phone*

Area Code

-

Phone Number

May we leave a voice mail message at the above number?*

Yes

No

May we text the above number?*

Yes

No

Client's Preferred Language:*

English

French

German

Italian

Spanish

Russian

Other

Client Employment Status (check all that apply)*

Full Time

Part Time

Student

Unemployed

Disabled

Legal Guardian Name (if minor client)*

First

Last

Relationship to minor client*

Legal Guardian Phone*

Area Code

-

Phone Number

Legal Gardian's Preferred Language:*

English

French

German

Italian

Spanish

Russian

Other

May we leave a voice mail message with legal guardian?*

Yes

No

May we text the legal guardian's number?*

Yes

No

Referral Source

Referring Agency

Name of Agency Contact:*

First

Last

Referring Agent Email:*

Email of referring person

Cell Phone Number for referring agency

Area Code

-

Phone Number

Office Phone Number for Referring Agency:*

Area Code

-

Phone Number

Extension:

Date of referral

Client Information

Please check all traumatic events the client has experienced (past or present):*

Adult physical assault

Adult sexual assault

Adult sexually abused/assaulted as a child

Bullying (verbal, cyber, physical)

Child sexual abuse/assault

Child physical abuse or neglect

Domestic and/or family violence

Stalking/Harassment

Teen Dating Victimization

Other (Please explain below)

If other, please list in box below.

Please check all the symptoms below for which the client needs personal counseling:*

Excessive worrying

Concerned about mental health

Lack of motivation

Find it difficult to express my feelings

Feeling sad or down

Have had difficulty with friends

Irritable/angry

Lack self-confidence

Life Loss or death of a significant person

Thoughts of harming myself or another person

Tantrums

Loss of appetite

Bothered by troublesome thoughts

Concerned about my relationship with my partner

Difficulty making decisions

Feeling overwhelmed

Have deliberately injured myself

Have had problems with sleep

Lack meaning in my life

Lonely, do not feel connected

Sexual assaualt, past or current sexual abuse

Suicide attempts

Impulse control

Other (Please explain below)

Please explain presenting problems:

Does the client have any mental health diagnoses?*

Yes

No

Please list all mental health diagnoses*

Services Information

Services Requested (check all that apply):*

Behavior Modification Counseling

Domestic Violence Counseling

Family Counseling

Grief and Loss Counseling

Individual Counseling

Sexual Abuse Counseling

Social Interpersonal Skills

Survivor Counseling

Trauma Recovery

Is the client currently involved with another counselor?*

Yes

No

Does the client have an open case with the Department of Social Services?*

Yes

No

DSS Caseworker Name:

First

Last

Office #*

Area Code

-

Phone Number

Cell #

Area Code

-

Phone Number

Would the client prefer*

Teletherapy (remote)

On-Site (office)

In-Home

Please Note: The agency is not allowed to complete on-site or in-home visits until further notice.

The Parenting Place

1039 S. Pendleton St.
Easley, SC 29642
864-898-5583

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