Referral Form


Referral Form
621 Scott Street
Covington, KY 41011
Phone: (859) 412-4308
Fax: (859) 538-5121
[email protected]
The following individual has been referred for services and is instructed to call the
above number within seven (7) days of referral date to schedule an assessment.
Participant’s Name: _______________________________________________ Date: _________________
Phone Number: ______________________________ Case Number: ____________________________
Foundations for Living Program (Life skills for those in recovery)
A psycho-educational group designed to explore, consider, and resolve the
underlying struggles that lead to the use of negative coping skills.
Anger Management
A psycho-educational group for individuals who have allowed their anger and
aggression to lead to unhealthy or unlawful behaviors.
Men’s Domestic Violence Program (Batterer Intervention)
A psycho-educational group designed to support the immediate and long term
cessation of violence against intimate partners and family.
Women’s Alternatives to Violence Program
A psycho-educational group for women who use any combination of control,
force, or violence in their intimate relationships.
Co-Parenting Seminar
A Seminar style class in which separated or separating parents learn how to
effectively co-parent their children.
Trauma: The Effects of Abuse & Neglect on Children
A seminar discussing the social, emotional, and physical effects of trauma on
each developmental level of childhood and its lasting effects on adulthood.
Referring Judge/Agency: __________________________________________________________________
Comments: __________________________________________________________________________________
White Copy – Court
Yellow Copy – Participant
Pink Copy – Mainspring Wellness