Individual, Conjoint, Family, Or Group Therapy Referral Form
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4Individual, Conjoint, Family, or Group Therapy Referral Form
Child Welfare Services
One Client per Referral Form. SW to complete all pages.
SW INFORMATION
Date:
Name of SW:
Phone #:
Fax #:
SW Email:
Region/Centralized Program:
Program:
<select>
<select>
PSS Name:
PSS Phone #
PSS Email:
PSS Signature:______________________________
NOTE to provider: Central # to Locate SW: 858.694.5191 *if you are unable to locate the SW with information provided above.
TERM website for Initial Treatment Plan/Update report templates: https://
CLIENT/CASE INFORMATION
Name of Client:
Gender:
DOB:
State ID/Case #:
Person #:
<select>
Insurance:
If “Other”, please specify:
<select>
If Client has Medi-Cal, MC#:
Ethnicity:
If “Other, please specify:
<select>
Language:
If client is a child/youth indicate language of their parent:
<select>
<select>
Client’s/Caregiver’s Name and Address (including facility name, if any):
Client’s/Caregiver’s Phone Number:
Voluntary
Court-Ordered
Pre-jurisdiction Next Court Date:
Date faxed/mailed to provider or OptumHealth TERM:
Protective Issue(s): (check all that apply):
General Neglect
Physical Abuse
Emotional Abuse
Sexual Abuse
Severe Neglect
Client is being referred for the following modality:
<select>
Client is being referred for consideration of the following therapeutic
intervention:
<select>
Transportation issues/limitations:
Scheduling preferences [evenings/weekends only, etc.]
TERM Provider name (if known) :
Describe the incident that brought this family to CWS’ attention (i.e. The safety concern that resulted in CWS
involvement; Harm Statement):
Date of the incident:
What is going on in the case right now (i.e. Case Plan elements; Danger Statement and Safety Goals):
Why is this service being requested at this time (INCLUDE emotional, social, behavioral, developmental concerns re:
a child/adolescent OR specific mental health concerns about the parent):
Other agencies/professionals providing services to client and/or their family system:
CHECK ALL THAT APPLY:
A CHILD IN THIS CASE IS UNDER 3 YEARS OF AGE: W&I Code 361.5 (a)(2) limits reunification services in these cases to 6 months.
However, W&IC 366.21(e) permits services to be extended up to 6 additional months if it can be shown that there is a substantial probability that
the child will be returned to the parent/guardian by the end of that time.
04-176A (02/14) L2
Page 1 of 4
County of San Diego/HHSA/CWS
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