CAC CLIENT COUNSELING REFERRAL FORM

This referral form is for the Family Services Child Advocacy Center to use when referring their clients to counseling at Family Services. If you have any additional documentation you wish to share concerning a referred client, please attach to this form or email it directly to Jasmine Stimac, jstimac@familyservicesforsyth.org. Please fill out a separate referral form for each person being referred, even if they are parent/child.

CAC CLIENT COUNSELING REFERRAL FORM

This referral form is for the Family Services Child Advocacy Center to use when referring their clients to counseling at Family Services.

CAC Child Referral Type:
Is the client in counseling elsewhere right now?(Required)
Please select the primary spoken language of the client(Required)
Client's Gender(Required)
Client's Gender Pronoun(Required)
* Note that this should be the non-offending parent/caregiver who we will contact to initiate counseling services
Please select the primary spoken language of the parent/guardian
Insurance Information(Required)

Referrer Information

Complete this section so we can contact you after the referral has been contacted.
Has the client been made aware that you are referring them?(Required)
Drop files here or
Max. file size: 50 MB.
    MM slash DD slash YYYY
    Consent(Required)
    List