Counseling Referral Form (Court)
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Client Information:
Client Name:
Phone
#: |
| Case Numbers:
(if applicable)
C-
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or
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(DHS Only) KK:
Date of
Sentence:
(if applicable)
Date of Birth: |
Referral Source Information: (Name of person who needs progress
reports, incident reports, UA results, etc.) |
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Referral Name:
Work Number:
Fax Number: |
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Email
Address:
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| Recommended Services: |
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DUI
Assessment |
English |
Spanish |
Consists of one 2 ½-hr. session. |
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Substance
Abuse Assessment |
English |
Spanish |
Consists of one 2 ½-hr. session. |
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10
Hour ADSAC (DUI) School |
English |
Spanish |
Consists of three 3 ½-hr. sessions. |
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24
Hour ADSAC (DUI) School |
English |
Spanish |
Consists of twelve 2-hr. sessions. |
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Victims
Impact Panel.
Consists of one 2-hr. session, facilitated by (MADD)
Mothers Against Drunk Driving |
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DUI
Outpatient Programs |
English |
Spanish |
6-week
program |
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12-week
program |
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(Relapse
Prevention/Aftercare Programs)
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6-week
program |
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12-week
program |
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(lmpulse
Control/Criminal Thinking) Coping
Skills Program -
12-24 week
program for adolescents and adults, designed to
challenge and correct irresponsible and criminal thinking and
behavior, 1 ½ hours per week |
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Anger
Management/Coping Skills Program-12-week
program for adolescents and adults, 1 ½ hours per week.
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Early
Intervention Programs |
English |
Spanish |
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6-week substance
abuse education program for adults and 12-week substance
abuse education program for adolescents. Random Drug
Testing provided (if checked above)
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Extended
Outpatients Programs |
English |
Spanish |
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12-24 week program
(2-8) hours per week) for adults and adolescents. Random
Drug Testing, individual, group, and self-help meeting
attendance is required. |
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Intensive
Outpatient Programs
- 6 week program (9-12 hours per
week) for adults.
6 week program (6-hours per
week) for adolescents. Individual, group, and self-help
meeting attendance is required. Random Drug Testing
provided (if requested.) |
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Level Of
Identified Risk: (Level
checked indicates the risk of relapse/continued use or
other behavioral/family problems) |
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Low
Risk - (Risk is minimal) Early
Intervention referral is indicated |
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Medium
Risk
- (Risk is moderate) Extended Outpatient referral with
additional family services is indicated |
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High
Risk - (Risk is extreme)
Intensive Outpatient referral with additional family
services is indicated |
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Case history, evaluation results, or
comments supporting assigned level of risk: |
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