Referral Form for Services
Strength-Based   |   Family-centered   |   Trauma-informed   |   |   Outcomes-driven

Please indicate the appropriate office desired for services.
Please call us if you have any questions about how to complete this form.
Complete all the information so that we can proceed as quickly as possible.
Charleston
Email:Charlestonreferrals@justiceworksbc.org
Phone:Phone: 843-974-5934
Fax: 803-234-6135		 Florence
Email:Florencereferrals@justiceworksbc.org
Phone:Phone: 843-407-4167
Fax: 843-407-4378
Greenville
Email:Greenvillereferrals@justiceworksbc.org
Phone:Phone: 864-448-3448
Fax: 864-448-3449		 Horry
Email:Horryreferrals@justiceworksbc.org
Phone:Phone: 843-488-1615
Fax: 843-488-1616
Richland
Email:Richlandreferrals@justiceworksbc.org
Phone:Phone: 803-234-6134
Fax: 803-234-6135
Date of Referral:Click to pop open the Welligent Date Picker
Reason for Referral:
Services Requested: Diagnostic or Parenting Assessment Family Support
Therapy Services Life/Social Skills
Behavioral Services Uknown/Unsure
Referring Person Information
Referring Person First Name Referring Person Last Name
Referring Person Phone Number Referring Person Email
Is this a self-referral? Yes   No
Referring Organization Name
Referring Organization Street Address
Referring Organization City
Referring Organization State
Referring Organization Zip
Client Information
Client First Name Client Last Name
Client Date of Birth: Click to pop open the Welligent Date Picker
Client Gender: Client Primary Language:
Client Marital Status: Client Race:
Client Street Address:
Client City:
Client State:
Client Zip:
With whom does the Client reside?
Client Social Security #: (Numbers Only. No Dashes)
Client or Caregiver Email Address:
Caregiver Contact Information (if client is a child)
Caregiver First Name Caregiver Last Name
Caregiver Phone Number:
Relationship to client:
What are the involved agencies (Check all that apply)? Continuum of Care Juvenile Justice
Department of Social Services Department of Mental Health
Department of Disabilities & Special Needs
Client Insurance Information
Primary Insurance: Policy/Plan #:
Policy Holder:
Secondary Insurance: Policy/Plan #:
Client Mental Health/Behavioral Health Information
Is client currently receiving behavioral health services? YesNo
If client is receiving behavioral health services, what is name of the Provider?
If client is currently receiving behavioral health service, what is the name of the Facility of the provider?
Please list any current or past behavioral health services client has received(i.e., Behavior Modification, Therapy, Family Support Services, Psychosocial Rehabilitative Services, etc.)
List Current Medications (name/dosage/prescribed by)
Current Diagnosis (If Known)
List any current or prior medical conditions, intellectual, impairments or physical disabilities that a provider needs to accommodate.
Was a CALOCUS completed?YesNoUnsure
Was a Diagnostic Assessment completed?YesNoUnsure
Was a Psychiatric Evaluation completed? YesNoUnsure
**Please email the above documents to the email address of the preferred service location. Include the following documents, CALOCUS, CBCL, DIAGNOSTIC ASSESSMENT, PSYCHOLOGICAL, MEDICAL, or PROGRAM Notes, DISCHARGE Notes, etc.