Professional Referral & Care Placement Intake

Trusted Sources / Waymark

In Partnership WithPathways2Life

For attorneys, legal staff, courts, schools, churches, case managers, healthcare providers, and other professionals seeking appropriate care placement for a client. Client names are optional.

1

Referral Source

2

Client Identification

3

Primary Objective

4

Presenting Concerns

5

Urgency & Risk Screening

6

Mental Health History

7

Substance Use History

8

Court / Legal Involvement

9

Placement Requirements & Preferences

12

Insurance & Funding

13

Family & Support System

Fields marked * are required. Client information is kept confidential.