REFERRAL FORM
COMPLETE & SUBMIT OR CONTACT OUR OFFICE

Client Name:  _______________________  Gender    M  F   Age:____ Date: ____/_____/_____  PH#:___________
Alt#: ___________ DOB: ____/____/____  Grade: ______  School/Employer: ______________  Race: ___________
 Non Hispanic  Hispanic SSN#:____/____/_____ Medicaid#:______________Guardian Name: __________­_________ Insurance Agency:_____________  Ins. #:___________ Marital Status: ______Residence:_________________________ State:____ City:_________ Zip:_______ Employer: ________________  Title: _________ WK#:__________
​Emergency Contact: ________________ PH: _____________  Email: ______________
 
Presenting Issue / Descriptive Behaviors: In Residential, Academic & Community Setting
___________________________________________________________________________
___________________________________________________________________________
Medication Status:
Present & Previous History: (Diagnosis, Prescribing Agency, Side Effects, Approx. Time & Etc.)
____________________________________________________________________________
​____________________________________________________________________________
Counseling Status:
Present & Previous History: (Type, Providing Agency, Approx. Time/ Frequency & Etc.)
_____________________________________________________________________________
_____________________________________________________________________________
Suicidal Status:
Present & Previous (Describe Behaviors, Treatment, Ideations, Time Frame /Frequency & Etc.)
_____________________________________________________________________________
_____________________________________________________________________________
Primary Physician & Psychiatric Evaluation: _____________________________________________________________________________
_____________________________________________________________________________
Referral Source: _____________________  Title: ____________ Phone: _________________Email:_________________
Check Requested Eclectic Counseling Services Department:
() Counseling – CPST, PSR, Psychotherapy & Psychiatric Care
() Mentor - CSOS Independent Living Skills Building Program (Spanish, French, English & Creole Speaking)
() Transportation Service 

No Transportation:
​No Problem We Come To You!!

  • THERAPY FOR THE WHOLE FAMILY
  • PSYCHIATRIC CARE - MEDICATION  MTHLY
  • SCHOOL SUPPORT & VISITS
  • WEEKLY HOME VISITS
  • CAREER COUNSELING & PREPARATION
  • MENTOR SERVICE AVAILABILTY
  • ​GOVERNMENT RESOURCE SUPPORT
  • LICENSED & CERTIFIED COUNSELORS ONLY
  • ​COURT APPEARANCES WHEN NECESSARY
  • NEW ORLEANS - LOCALLY OWNED
  • HOSPITAL VISITS WHEN NECESSARY
  • AGES WE SERVE: 0-65+
WE ARE QUALIFIED THROUGH LOUISIANA'S MEDICAID SYSTEMS MAGELLAN, CSOC, BLUE CROSS BLUE SHIELD & THE BAYOU HEALTH PLANS
​

E.C.S. Mentor Program

A Mentor Program that meets youth where they are yet prepares them for greater.  Our goal is to provide youth with Independent Living Skills Building Techniques to become independent, successful adults which makes for an overall better quality of life.  

24 HOUR CRISIS HOTLINE BY A QUALIFIED LICENSED COUNSELOR

WE HAVE SERVED SURROUNDING PARISHES SCHOOL SYSTEMS, COURT SYSTEMS, STATE PROGRAMS, COMMUNITIES, COORDINATED SYSTEM OF CARE REFERRALS, ORLEANS  DETENTION ALTERNATIVE PROGRAM, CHURCHES, HOUSING DEVELOPMENT PROGRAMS & MORE
WE  ACCEPT PRIVATE INSURANCES:

WE SEE YOU GETTING BETTER:
COUPLES COUNSELING & FAMILY UNITY
images By: www.slomarriagecounseling.com  & www.123rf.com

LAKEFRONT PROFESSIONAL BUILDINGS
​​6305 ELYSIAN FIELDS AVE. SUITE 404 
​NEW ORLEANS LA. 70122
PH: 504.265.0996 FX: 504.265.8340
7707 WACO AVE. BATON ROUGE., LA. 70806
Office: 225.227.2877
ECLECTICCOUNSELINGSERVICES@GMAIL.COM​