Ascent Monroe Referral — Ascent

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Folder: Our Services

Folder: Referral

ASCENT MONROE

For more information, questions, or to speak to an Ascent Representative, e-mail Rebecca Gauthreaux at rgauthreaux@ascentlife.org. To send clinical documents or other paperwork, please email to rgauthreaux@ascentlife.org.

Submit the following form to refer a youth to Ascent Monroe.

Date *

MM

DD

YYYY

Youth's Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Youth's Social Security Number

(This information is not necessary at this time but could speed up the referral process)

Youth's Insurance

Medicaid

Private

Unknown

Legal Guardian Name *

First Name

Last Name

Legal Guardian Phone 1 *

(###)

###

####

Legal Guardian Phone 2

(###)

###

####

Line

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Line

Name of youth's placement, if different from guardian

Line

Referring Agency

If applicable

Agency Contact Person

Agency Contact Phon No.

(###)

###

####

Referring Agency/Individual Contact Email *

Line

Is the family comfortable with face to face visits at this time?

Reason For Referral (check all that apply)

Abandonment

Aggression/Assault

Behavioral Problems

Death of Family Member

Delinquency

Developmental Disability

Emotional Disability

Family Conflict

Legal Issues/Incarceration

Physical/Mental/Emotional/Sexual Abuse

Runaway

School Problems/Truancy

Substance Abuse (Youth or Parent)

Suicidal Ideation/Homicidal Ideation

Reason For Referral/Additional Comments

Thank you!

Community connections booklet