Child/Adolescent Referral Form

Name of Attorney: Name of Attorney: First Last
Attorney Phone: Attorney Phone: - ### - ### ####
Attorney Email:

Confirm Email Address
Legal Assistant/ Paralegal Name: Legal Assistant/ Paralegal Name: First Last
Legal Assistant/ Paralegal Email:

Confirm Email Address
The evaluating clinician will be reaching out to gather additional details prior to scheduling the evaluation with your client. What is your preference for communication?

The evaluating clinician will be reaching out to gather additional details prior to scheduling the evaluation with your client. What is your preference for communication? Phone call with attorney Email attorney Phone call with legal assistant/paralegal Email legal asisstant/paralegal
Date report is needed by: Date report is needed by: / MM / DD YYYY

Please note that evaluations completed within one year of the expected court date are considered current. Evaluations completed outside of that may require an updated evaluation.
Is this date flexible?

Is this date flexible? Yes No Other Other
Are you affiliated with any of these organizations?

Are you affiliated with any of these organizations? SOAR IRCO LCS Catholic Charities ICS None Other Other
How much can your organization contribute to the cost of this evaluation?
Is this an Equity Corps referral?

Is this an Equity Corps referral? Yes No
If this is an ECO case, what is the client ECO ID number?
Do you prefer that the evaluation be done via telehealth or in person?

Do you prefer that the evaluation be done via telehealth or in person? telehealth in person no preference Other Other
Is the client comfortable completing intake forms electronically?

Is the client comfortable completing intake forms electronically? Yes No
Is the client comfortable setting up a video appointment electronically?

Is the client comfortable setting up a video appointment electronically? Yes No
Will the client require assistance with the above?

Will the client require assistance with the above? Yes No
If needed, can you provide an office space for the evaluation?

If needed, can you provide an office space for the evaluation? Yes No
Does you client consent to the use of an interpreter?

Does you client consent to the use of an interpreter? Yes No
What type of visa is this client applying for?

What type of visa is this client applying for? Political Asylum SIJ (Special Immigrant Juvenile) Cancellation of Removal Other Other
Is the client an unaccompanied minor?

Is the client an unaccompanied minor? Yes No
Client Information
Child/Adolescent Name: Child/Adolescent Name: First Last
Phone: Phone: - ### - ### ####
Email:

Confirm Email Address:
Date of Birth: Date of Birth: / MM / DD YYYY
Age:
Birthplace:
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Language of choice:
Education:
School:
Number of siblings and ages:
List any known major health issues:
Relevant History:

Please note any known traumas or other relevant history.
Define the questions you want addressed in the psychological evaluation:
Can a declaration be submitted to the evaluator?

Can a declaration be submitted to the evaluator? Yes No Other Other
Please check the records you can provide to the evaluator.

Please check the records you can provide to the evaluator. Medical Educational Past therapy or psychological assessments
This client may qualify for funding. Please state the estimated monthly income & number of people living in the household:
Legal Guardian
Name: Name: First Last
Phone: Phone: - ### - ### ####
Email:

Confirm Email Address
Does this person live with the child/adolescent?
If not, please provide the child's caregiver contact information.
(Name/Phone / Email)
Birth Parents- if different from caregiver
Name: Name: First Last
Date of separation Date of separation / MM / DD YYYY
Describe the current communication between child and parent(s) ( Please specify if there are any legal parameters regarding communication ie supervised visits, no contact order)
Name: Name: First Last
Date of separation Date of separation / MM / DD YYYY
Describe the current communication between child and parent(s) ( Please specify if there are any legal parameters regarding communication ie supervised visits, no contact order)
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Child/Adolescent Referral Form

Child/Adolescent Referral Form

Client Information

Legal Guardian

Birth Parents- if different from caregiver