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