Mental Health Referral Form "*" indicates required fields Date of Referral* Name* First Last Date of Birth* Age* Child’s Medi-Cal No.* Issue Date* Phone*Address* Street Address City ZIP / Postal Code Is the parent/caregiver aware that child is being referred for therapy with Phoenix House?* Yes No If not, please make sure to discuss with parent before submitting referral.Name of Referring Party* Title* School/Agency* Contact No.*Symptoms and Behaviors* Sad/Depressed Tearful/Frequent crying Nervous/Anxious Withdrawn Irritable Distracted Does not listen Does not follow rules Hyperactive Unmotivated Thoughts of hurting self/others Recent Psychiatric Hospitalization Fighting/Physical aggression Argues/Talks back Amphetamines (Meth) Over the Counter Marijuana/Cannabis Alcohol Cocaine Opioids (Heroin) Hallucinogens (Shrooms, LSD) Unknown Other Symptoms and Behaviors* How long have you observed symptoms/behaviors?* Other behaviors/Comments*
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