Legal Aid of West Virginia
Family Advocacy Support and Training Referral Form
(Fax completed referral form and authorization to (304)-414-0418

Date of Referral: ___________________________	Referring Organization: _______________ 

Contact Person: ___________________________     Phone Number: _____________________ 
Contact Person Address:_________________________________________________________                                                     
                                     
Name of Child: ________________________________________________________________    
Child’s Date of Birth: __________________ Child’s Social Security No.__________________
Current Address: ______________________________________________________________
Name of Legal Guardian: _______________________   Telephone: _____________________
Address (if different than above): _________________________________________________                                                     

The Child is experiencing or has experienced (check all that applies):

____Anxiety and/or stress related difficulties	____Behavioral problems
____Attention Deficit disorders or difficulties	____Substance abuse
____Impulse control difficulties		            ____Academic difficulties
____Learning disorder or difficulties		            ____Peer or Social difficulties
____Depression				            ____Challenges associated with                                                    developmental disorders and/or intellectual disabilities
____Other: ___________________________	
What is/are the child’s diagnosis? _______________________________________________
Date of Diagnoses: __________________________________________________________

Please provide a brief summary of advocacy needed:                                                                  
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

(Fax completed referral form and authorization to (304)-414-0418
(Please call 1-800-642-8279 with any questions)     
Revised 11/23/09
Revised Oct. 2009

Legal Aid of West Virginia, Inc.
Family Advocacy, Support and Training Project
Authorization to Release or Obtain Information

I, _______________________________________, hereby authorize ______________________ to provide ________________________________________ with the information listed below regarding my child___________________________________.

____ All records detailing my child’s behavioral health care treatment or needs;
____ Personal records, including correspondence, detailing my child’s behavioral health needs;                     
 	____ Court documents, contractual agreements and/or any legal documentation and information that contain information relevant to my child’s behavioral health needs and/or treatment;                   
____ Educational tests or evaluations, including individualized education plans, triennial assessments, psychological and speech evaluations, and teachers’ observations and evaluations.
	____ Other: _______________________________________________________

      I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above.

     I understand that there are some circumstances where this information may be re-disclosed to other parties.  Legal Aid will disclose private health information only when necessary to achieve the objectives for which we are assisting the Client.

     I may revoke this authorization at any time, except with respect to the actions already taken in reliance on this release.  My revocation should be in writing and sent to any of my sources of Legal Aid of West Virginia.

     Legal Aid of West Virginia will give me a copy of this form if I ask, and I may ask the source to allow me to inspect or get a copy of material to be disclosed.

     This authorization shall be valid for 12 months from the date signed.

______________________________________________		__________________
Signature of Parent or Guardian	   				Date