SOS Pre-screening and Referral Services
                   
Please fill in the following information to the best of your ability.  All information will be kept extremely confidential.  We will review the information and contact you shortly.
               
Referral Information
Name: Birthdate: Age
 
Contact Number: Email:  
  home
cell
 
Referral Type:
Self
Professional  
  If Professional referral please answer below:
  Role  
  Name  
  Email  
  Phone  
           
Current Agency Status:
VACFSS          
   
Circle 5          
   
Metis Family Services        
   
MCFD          
   
FVACFSS          
   
Xyolhemeylh        
   
Other  
 
Current Housing Status:
With Biological Family  
 
With  Foster Family  
 
Independent  
     
  City Residing in:  
 
Caregiver Name: Phone:  
                 
  School:   Grade:
 
Reason for Referral:
 
Primary Concern:
 
Diagnoses
 
    Diagnosis     Confirmed   Suspected  
  Autism / Asperger's    
 
 
  Fetal Alcohol Spectrum Disorder (FASD)
 
 
  Attention Deficit (ADD/ADHD)  
 
 
  Conduct Disorder    
 
 
  Depression    
 
 
  Anxiety      
 
 
  Post Traumatic Stress Disorder (PTSD)
 
 
  Oppositional Defiance Disorder (ODD)
 
 
  Reactive Attachment Disorder (RAD)
 
 
  Borderline Personality Disorder
 
 
  Dissociative Identity Disorder (DID)
 
 
  Other
 
 
 
Services you are interested in:
 
  Programs   Therapies  
 
SOS programming  
Art  
 
PDAS (Fee for Service)
Music  
 
Caregiver support  
Drama  
 
Academic  
Narrative  
 
Cultural  
Expressive  
 
Transition to Adulthood
Trauma Focused CBT  
 
Year Intensive Housing
Neurofeedback  
     
Cognitive Remediation  
 
Other  
 
Have you ever received services from SOS before?
 
Yes  
No  
 
If Yes, please provide approximate date of Service:  
 
Please press "Submit" below to finalize the referral.
 
Thanks so much for your interest and we look forward to contacting you soon,  
Lise' DeLong, Ph.D., CPCRT  
Clinical Director