Counseling and Skills Group Referral Form

Date:
Language of Primary Caregiver:
Is Youth on Formal Probation
Do You Have Divorce Decree Papers
*This explains if you have the right to consent for the youth to receive mental health services.

Services Requested

Services Requested
Classes/Support Groups (Choose One):

Get Immediate Help

Call 817.335.HOPE (4673)

OR

1.888.296.8099

Answered 24 hours a day

Not an emergency services phone number. Call 911 for medical emergencies.

YOUTH EMERGENCY SHELTER
TURNING POINT
SUICIDE PREVENTION
REPORT CHILD ABUSE

In Texas: 1.800.252.5400
Nationwide: 1.800.4.A.CHILD

Under $25,000

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