contact stillwaters
Sunday, May 20, 2012
Stillwaters Counseling Referral Form
* denotes required field
Referral Source:*
Patient Name:*
Maiden Name:
Date of Birth:*
Format: MM-DD-YYYY
Age:*
SSN:
Race:*
Sex:*
Married:*
  No    Yes
County:*
School:*
  Grade:  *
Legal Guardian:*
  Relationship:  *
Address:*
City:*
State:*
Zip Code:*
Home Phone:
Format: 5555555555
Cell Phone:
Work Phone:
Emergency Contact Name:*
  Emergency Contact Phone:  *
Household Members:
Referral Reason:*
Is there DJJDP involvement?:*
  No    Yes
Is participation in this program court ordered?:
  No    Yes
Is participation in this program a part of a diversion plan/contract?:
  No    Yes
Problem Behaviors (Check all that apply):
  Delinquency - Property
  Delinquency - Person
  Delinquency - Victimless Crime
  Runaway
  Truancy
  Ungovernable
  Neglected
  Excessive Dependence of Parents
  Physical/Mental Abuse
  Academic Failure
  Assault/Aggressive Behavior
  Feelings of Anxiety
  Fire Setting
  Gang Associate
  Negative Peer Associations
  Other
  Poor Social Skills
  Prostitution
  School Behavior Problems
  Self-Mutilation
  Sexual Abuse
  Sexual Offense
  Sexually Active
  Stealing
  Substance Abuse
  Suicide Attempts
  Suicide Threat(s)
  Temper Tantrums
  Withdrawn, Depression
Other:  
Insurance Information
Insureds Name:*
  Relationship to Patient:  *
Insureds Date of Birth:*
Format: MM-DD-YYYY
SSN:
Occupation:
Insurance Company:*
Group #:
Employee #:
Insurance Company Address:
Deductible:
Co-Pay:
Insurance ID:*

Consents: I authorize Stillwaters to release any information including the diagnosis and the record of any treatment or examination rendered to my child during the period of such care to my insurance company (above) and/or other health practitioner desgnated by the insurance company.

I authorize and request my insurance company to pay directly to Stillwaters benefits otherwise payable to me.

I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on behalf of my dependents.

I authorize Stillwaters to communicate treatment information/summaries to the following:

Primary Care MD:*
Other: