Make a Referral | marcsagency

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Getting the help one needs begins with talking to a competent and trusted professional. The goal of feeling better is a phone call away. An Intake Coordinator will work with you in setting up an initial appointment to assess your (or your child’s) needs. Once admitted into services, a Mental Health Professional will partner with you and/or your child to explore the nature and history of your concerns, help identify and set specific goals, and work with you and/or your child to create a treatment program tailored to those individual needs and circumstances.

Make a referral below or Contact us.

Please fill out all Fields Below

Name:

Date of Birth:

Social Security Number:

Age:

Sex:

Address: House Number / City / State / Zip Code

Medicaid Number:

Parents/Guardian Names:

Client or Guardian Email Address:

Home Phone:

Work Phone:

Cell Phone:

List significant people in the home (please include age and relationship):

Reason for Referral (Presenting Problems & Needs):

Referred by Name:

Referred by Email Address:

Referred by Contact Number:

School Name:

Primary Care Physician Name:

Primary Care Physician Phone #:

Probation Officer Name:

Probation Officer Phone #:

Psychiatrist/Psychologist Seen (Yes or No):

Psychiatrist/Psychologist Name:

Psychiatrist/Psychologist Phone #:

Diagnosis:

The MARCS Agency has received your Referral.

We appreciate your continued trust in our services.

Thank You.