If this is an emergency, do not use this form
This form is checked during office hours only. It is not monitored around the clock, and submitting it does not alert anyone immediately.
If the person you are referring is in danger right now:
Call 911 for immediate danger · Call or text 988 for the Suicide & Crisis Lifeline, 24 hours · Call 211 for 24-hour crisis counselling in English, Spanish, and Creole · Call the Florida Abuse Hotline at 1-800-962-2873 to report abuse or neglect
Referral Screening Form
Use this form to refer a client to A New Life in Christ Ministries and Resources for outpatient services, individual and family counselling, substance abuse support, the SEED after-school program, or PSR for adults.
This form is for schools, agencies, clinicians, and caseworkers. If you are a family looking for help for yourself, please request an appointment here instead, or call (786) 396-3144.
Before you start
- This form is long. It collects clinical and demographic detail, so allow about 15 minutes and gather what you need first.
- It does not save partway through. Finish in one sitting.
- Have ready: client name and address, date of birth, guardian and emergency contact details, insurance or Medicaid number, primary care physician details, school and grade, and the presenting concerns.
- Only share what you are authorised to share. Make sure you have the consent or release you need before submitting clinical information about a client.
- Questions? Call (786) 396-3144 before submitting if you are unsure whether this is the right referral route.