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Required format:

Family Tree Referral Form

Returning?

A A A

Thank you for your referral into the EMPOWERR Family Tree program. Please complete the survey below with all of the information requested. Once received, a member of our team will be in touch with you.

If you have additional questions or concerns, please reach out to Kayla Visser at visser@musc.edu or 843-792-8356

Important Note for Referrals: We request that referral source contact the patient's parent or guardian to inform them that they are being referred to the Family Tree program.

Thank you!

Who are you seeking services for?

* must provide value

Myself

An individual that I am the parent/guardian of

An individual within my school or organization

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School Name

Liberty Hill

Lucy G. Beckham High School

Wando High School

Other

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School/Organization Name

* must provide value

Referral Contact Person

* must provide value

Referral Contact Phone Number

* must provide value

Referral Contact email address

* must provide value

Do you as the referring entity need to know whether the adolescent you are referring is receiving follow up services with our program for referral coordination purposes? If so, please indicate below.

Patient Name

* must provide value

Patient Date of Birth

* must provide value

M-D-Y

Patient phone number

patient email

Patient Identified Race/Ethnicity

Patient Identified Gender

* must provide value

Patient Language

* must provide value

if other, please specify

* must provide value

Patient Grade Level

* must provide value

Caregiver Name

* must provide value

Relationship to patient

* must provide value

Caregiver phone number

* must provide value

Caregiver email

* must provide value

Caregiver Language

* must provide value

if other, please specify

* must provide value

Caregiver Address

* must provide value

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What is the primary concern for this patient?

* must provide value

Substance use with co-ocurring trauma Substance use without co-ocurring trauma

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Select all that apply

* must provide value

Sexual Abuse/Assault

Physical Abuse/Neglect

Neglect

Witnessing Domestic Violence

Intimate Partner Violence (Victim of)

Witness of Community Violence

Loss by Homicide

Loss by Suicide

Human trafficking

Other traumatic experience

Unknown traumatic experience

If other, please specify

* must provide value

Select all substances being used

* must provide value

Electronic cigarettes (vapes, e-cigarettes, etc.)

Tobacco (cigarettes, chewing tobacco, cigars, etc.)

Alcoholic beverages (beer, wine, liquor, etc.)

Cannabis (Marijuana, pot, grass, hash, etc)

Cocaine (coke, crack, etc.)

Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)

Methamphetamine (speed, crystal meth, ice, etc.)

Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)

Sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, Rohypnol, GHB, etc.)

Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)

Street opioids (heroin, opium, etc.)

Prescription opioids (fentanyl, oxycodone, hydrocodone, methadone, buprenorphine, etc.)

Other substance(s)

Unknown substances

if other, please specify

* must provide value

Please specify frequency of use for each substance selected

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Do the legal parents/guardians know about this referral?

* must provide value

no yes

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Any other relevant information

* must provide value

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Any other information that our staff should be aware of?

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Please upload any documents that you would like for us to have (phone screens from internal referrals, etc.)

Upload file

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