Community Services Division

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Resiliency Through Healing (RTH) External Referral

RTH External Referral

Referring Organization *

Name *

Name

First Name

Last Name

Title *

Phone *

Date *

Is the individual in Crisis? *

Yes

ELIGIBILITY CHECK

All boxes must be checked for client to be eligible for RTH services *

Client is between 14 – 25 years old

Client experienced a potentially traumatic event that occurred in childhood (0 – 18 years)

INDIVIDUAL’S INFORMATION

Preferred Language *

English

Spanish

Name *

Name

First Name

Last Name

Date of Birth *

Age

Call Back Number *

Email *

Address *

Address

City

State/Province

Zip/Postal

Presenting Problem

Additional Forms

Safety Plan

Risk Assessment

Custody Paperwork

Confirmation of Guardianship

Guardian Information (If applicable)

Preferred Language

English

Spanish

Legal Guardian Name

First Name

Last Name

Relationship to Client

Gurdian Contact Info
(List Guardian info if client is under 18yo)

Guardian Email

Guardian Phone

May We Leave a Voicemail?

Yes

Can We Communicate Via Text?

Yes

Only Interested in Group Counseling *

Yes

If you are human, leave this field blank.

READY TO Learn More?

Please complete the below form, and a member of our team will contact you.

Name *

Last *

Phone

City *

State *

Program Program

Message

Captcha

If you are human, leave this field blank.

Community Services Headquarters
4346 NW Loop 410
San Antonio, TX 78229

210-733-7932 phone

Resiliency Through Healing (RTH) External Referral

ELIGIBILITY CHECK

INDIVIDUAL’S INFORMATION

Guardian Information (If applicable)

Gurdian Contact Info(List Guardian info if client is under 18yo)

READY TO Learn More?

Gurdian Contact Info
(List Guardian info if client is under 18yo)