Mental Wellness Center LLC Referral Form
Please fill out every question so that we may process your request as soon as possible. Please reach out to us at mentalwellnesscenterllc@gmail.com or 201-364-8474 if you have any questions. Thank you!
Agency requesting services:
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Name of person completing form:
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Phone number/email of person completing form:
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Youth's Name
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Youth's CYBER ID:
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Youth's D.O.B.
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Month
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Day
Year
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Youth's Address
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Parent/Guardian's Name
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Parent/Guardian's Phone Number
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Does the youth currently have an active Medicaid?
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Yes
No
Authorization dates:
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How many hours per week?
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Service(s) requested:
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Full CST Evaluation
Cross-Battery Psychological Assessment
Psychological (Cognitive Functioning)
Comprehensive Substance Abuse Evaluation
Social Assessment
Speech & Language Evaluation
Educational Evaluation
Substance Abuse Screening
Psychiatric Evaluation
Personality Profile
Psychosexual Evaluation
IIC Services
BA Services
Mentoring Services
Please state if there are any language/gender preference for provider(s):
Please tell us about this family.
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Is there anything else we need to know?
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