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.

If this referral is for the parent/caretaker of a CAC child, please select referral type:
If this referral is for a CAC child, please select referral type:
FSI does not have a bilingual therapist at the moment. In order to engage in counseling at Family Services, the client and parent must speak English fluently. Does the referred client and their guardian (if applicable) speak English?(Required)
Is the client in counseling elsewhere right now?(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
Insurance Information(Required)
Family Services is In-Network with Blue Cross/Blue Shield, United HealthCare, CBHA, Medicaid and NC Health Choice. We also accept out-of-network insurances and self-pay clients.

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)