Call Us:  (781) 600-6074

Neighborhood Counseling and Community Services

Referral Form "Life Hacks for Teens" Skills-Based Counseling Group for High Schoolers

Location: Davis Square Somerville

Starting:  Fall, 2017 Date TBA
 
Child’s Name _________________­­­­­­­_______________________________   DOB____/____/___
 
Parent/Guardian Name   _________________________________________________________

Relationship to Client   __________________________________________________________

Home Address   ________________________________________________________________

Guardian Phone __________________________   Client Phone__________________________

Guardian Email______________­­­­­_____________ Client Email ___________________________

Insurance Carrier ___________________ Insurance Policy Number _____________________­_

Name on Policy___________________­­­­­­­__________________________­__DOB____/____/____

Referred By ­­­­­­_______________________________Phone  _______________________________

Email ____________________________________Agency  ______________________________

 Referral Notes __________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________

Please submit this form to Julie Catalano, LICSW   infonccsinc@gmail.com

403 Highland Ave. Suite 202, Room 5 Somerville, MA 02144

PH 781-600-6074 * FAX 1-800-401-3695