Referral & Therapy Form


Policies and Consent

In order for Cherish to assist you with obtaining therapeutic services, please complete and submit this form. By submitting this form, you acknowledge that you have read these policies and you consent to services and/or referrals from Cherish.

TRAUMA THERAPY PROGRAM - You are being referred as a Cherish client to therapy services. You have participated in a Cherish interview, unless there have been other circumstances of which you've discussed with Cherish. - As a Cherish family, you may be eligible for financial assistance for therapy services; if financial assistance is needed, please complete the attached Referral and Financial Assistance Application - Financial assistance is never guaranteed and is based on federal poverty guidelines, personal need, and current available funding.  - One automatically qualifies for financial assistance if income is at or below 138% federal poverty guideline.  If not but assistance is still needed, please provide proof of need, including proof of income and expenses, which will be reviewed by the clinical advisory board to determine if financial assistance will be provided.   - Understand that your insurance will be billed first, as applicable.  Cherish assistance may cover session costs, co-pays, or costs not covered by your insurance.   - Any financial assistance is provided to specifically address the trauma that involved a Cherish forensic interview. - Please abide by your provider’s specific cancellation policy.  Appointments cancelled without proper notice and no shows will not be tolerated.  This does not apply to emergencies or serious illness.   - Cherish will not pay any fees due to not following proper cancellation procedures or for no shows.
Parent/Guardian Name *
Parent/Guardian Name
Today's Date *
Today's Date
Name of Child *
Name of Child
Legal Guardian
Legal Guardian
Additional Legal Guardian
Additional Legal Guardian
Phone Number *
Phone Number
Address *
May we leave a voice message if no answer *
Is Financial Assistance needed in order to obtain services *
You may be asked to show proof of need for financial assistance.
Do you fall at or below the 138% poverty guideline? *
If not, you must provide proof of need (proof of income and expenses. Persons in Household (Col. 1)—FPL100% (Col. 2)—FPL138% (Col. 3) 1 $12,060 $16,642 2 $16,240 $22,411 3 $20,420 $28,179 4 $24,600 $33,948 5 $28,780 $39,716 6 $32,960 $45,484 7 $37,140 $51,253 8 $41,320 $57,021 Add $4,160 for each additional person if household has more than 8 people
Is there a Divorce Decree or other Court Order in place affecting the child? *
Date seen at Cherish
Date seen at Cherish
DCS Contact
DCS Contact
Law Enforcement Contact
Law Enforcement Contact
Name of Individual Completing Form *
Name of Individual Completing Form
I understand:
- Cherish has an obligation to keep my personal information, identifying information, and my records confidential.  I also understand my information will be shared among the Cherish Multidisciplinary Team in order to provide effective case management and I can choose to allow Cherish to release some of my personal information to certain individuals or agencies. - I do not have to complete a release form. I do not have to allow Cherish to share my information. Completing a release form is completely voluntary. - Releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from Cherish. - The risks and benefits of releasing the confidential information to the above organization or person. - A limited release of information can potentially open up access by others to my confidential information held by Cherish. - The specific information I want to be released and how it will be shared. I understand email is not confidential. - Cherish and I may not be able to control what happens to my information once it has been released and that the agency or person getting my information may be required by law or practice to share with others. - This release is valid when I check this box and complete this form and I may withdraw my consent to this release at any time either verbally or in writing.
Date Completed *
Date Completed
By checking this box and submitting this form, I acknowledge I have read these policies and I consent to services and/or referrals from Cherish. I authorize the release of the above stated information to Cherish. I further understand that this is not an acceptance of services and that Cherish has an ethical obligation to respect my right to privacy through the handling of information in a confidential manner. I hereby consent to authorize the release of information aforementioned. *