Referral at
CSI Behavioral Company, LLC
Intensive Family Intervention
Program Referral
Referral Date:

Services Provided:
In-Home Counseling
24-Hour Crisis Intervention
Educational Advocacy and Support

Parent Skills Training
Community Resource & Referral

Name of Child:
First: Last:
Date of Birth:
Education Information:
School Attending: Grade:
Is Child Receiving SST or Special Education?
If yes, please indicate which program:
Name of Parent/ Guardian:
First: Last:
Address: City: State: Zip:
Home Phone : Work Phone :
Referring Agency:
Agency Name:
Contact Person:
Medicaid / Peach Care #:
Referrer's Email:
Other Information:
Has Psychological Evaluation been completed?
(If yes, please fax referral.)
What are the behaviors currently displayed by child that are placing him/her at risk of out of home placement?
Is Child Court Involved?
(If applicable, please list court date, PO, etc.)