Therapy Referral Form – Child Advocacy Center of Aiken County

Today’s Date: *

Agency/Organization Name: *

Agency/Organization Address: *

Name: *

Title: *

Email: *

Phone: *

Please select one or more services you are requesting for this child. *

Child’s Name: *

Child’s Social Security Number: *

Child’s DOB: *

Child’s Age: *

Child’s Sex: *

Child’s Race: *

Does the client or custodian(s) have special needs that we need to be aware of? *

i.e. disability, language barrier, transportation

Contact Person’s Name: *

Date

Time

This person CANNOT be an alleged offender.

Home Address: *

Primary Phone: *

Secondary Phone:

Biological Mother Name and Address:

Biological Father Name and Address:

Other Person(s):

Step parents, foster parents, safety plan guardian, etc.

Case/Background Summary: *

Address: client Email:

What services has your agency provided to this child? *

Anything you would like us to know?