PEERS Parent Advocate Referral Form

PEERS Parent Advocate Referral Form

Complete this form to make a referral for family peer support services. Please provides as much detail as possible.
Child Information
Child Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Child Gender
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Insurance or Medicaid Company Name
Insurance/Medicaid Member or ID Number
School Child Attends
Parent/Guardian/Caregiver Information
Parent/Guardian/Caregiver Name(s)

First NameLast Name
Parent/Guardian/Caregiver Phone Number(s)
Please enter a valid phone number.Format: (000) 000-0000.
Parent Email
example@example.com
Does Parent/Caregiver have legal custody of youth?
If no, who has custody?
Referral Details
Reason for Referral
Please include mental health concerns, educational issues, juvenile justice issues, heath issues, safety concerns, etc. Please include other systems involved with youth, if known.
Is Child Currently Receiving IHBT, ICT, FFT, MRSS, or in Residential Placement?
Is this an agency referral or self/personal referral ?
Referral Contact Name

First NameLast Name
Referral Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring Agency
Agency Contact Name
Agency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Sending Diagnostic Assessment?
If yes, please upload below
Does Diagnostic Assessment include Family Peer Support Recommendation?
Sending Release of Information?
If yes, please upload below
File Upload

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Questions:
Referral questions, please contact PEERS@greenleafctr.org or call Courtney Ingram, PEERS Services Coordinator, on her mobile number at 330.803.0061
Should be Empty:

PEERS Parent Advocate Referral Form

Child Information

Parent/Guardian/Caregiver Information

Referral Details

Questions: