Youth Mental Health Referral Form

Youth Mental Health Referral Form

Mental health services for youth 5-18 provided by One Common Unity.

Clients must reside in DC in order to be eligible for telehealth/virtual services.

Young children (age 4 and under) and young adults (19-24 years old) are also eligible for services under special circumstances. *** We are currently on a waitlist, OCU will notify ONSE once a slot is available. Once a slot is available, OCU will reach out to the family directly.***

Agency/Organization*

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Program - Other

ONSE Program

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Staff's Name Referring Client*

Staff's Phone Number*

Staff's Email*

Client's Name*

Client's Pronouns

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Client's DOB*

Age*

Is client 15 years old or younger?*

Select

Parent/Guardian's Name*

Please ensure this is the minor's LEGAL parent/guardian.

Parent/Guardian's Phone Number*

Parent/Guardian's Email Address

Client's Phone Number*

Client's Email Address

How would the client like to be contacted?

Select

Where would the client like to meet with the clinician?*

Select

School Name*

What is client's preferred language?*

Select

Date of Incident

In what way was the client impacted by gun violence?

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Please expand on their connection to incident.*

Nature of Incident*

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Age of deceased

Incident Narrative

Does this client have any safety concerns?

Select

Safety Concern Narrative

Is the client displaying any of the following symptoms?

Please select all that apply.

Select

Background Information

If you have any additional background information on the client that you'd like to share, please do so. This information can support the clinician with building trust during initial meetings.

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