Professional Referral Form

1 Referring Professional Information

First Name

Last Name

Professional Title / Role

License Number (if applicable)

Organization / Firm / Agency

Court Jurisdiction (if applicable)

Phone

Email Address

Preferred Contact Method

Best Time to Reach You

2 Client / Parent Information

Parent / Client Full Name

Parent Phone Number

Preferred Language

Child's Age(s)

Has the parent been informed of this referral?

Yes — parent is aware

No — TTS may contact parent

Parent initiated this referral

3 Case Context

Case / Cause Number (optional)

Current Visitation Status

Level of contact being considered or ordered

Supervised visitation

Therapeutic supervised visitation

Facilitated conjoint sessions

Reunification therapy

Not yet determined

Is there an upcoming court date?

Court / Hearing Date (if known)

Presiding Judge / Department (if known)

5 Documentation & Release

Which documentation do you need upon completion? Check all that apply.

Verification of enrollment

Verification of attendance

Program completion letter

General participation summary

Readiness checklist results

Clinical observations

Recommendations for next steps

Level-of-care recommendations

Send documentation to (name / title)

Email or fax for documentation

Authorization confirmation: I confirm I have authorization to share this client's information with The Therapeutic Solution & Family Trauma Treatment Center for the purpose of this referral. A signed release of information may be required before documentation is returned.

6 Urgency & Scheduling

How soon is intake needed?

Immediately — within 1 week

Within 2–3 weeks

Within the month

No urgency — standard scheduling

Anything else TTS should know before intake?

By submitting this form, you confirm the information above is accurate to the best of your knowledge. A member of the TTS clinical team will follow up within 2 business days. For urgent matters, contact TTS directly at (702) 485-1313.

Family Reunification Parent Preparation Program

1 Referring Professional Information

2 Client / Parent Information

3 Case Context

4 Reason for Referral

5 Documentation & Release

6 Urgency & Scheduling

The Therapeutic Solution & Family Trauma Treatment Center