Referral Form for Sex Offender Specific Evaluations
Heather Wilkerson, MSW, LCSW
Court Counselor’s Name:
Court Counselor’s Phone Number:
Court Counselor’s Email Address:
Client’s Next Court Date:
Social Security Number:
Birth Date:Medicaid #/Other insurance:
Is there a doctor’s office listed on the Medicaid card?If so, what is the name and phone number of the clinic?
Client’s legal guardian’s name?
Client’s legal guardian’s phone number?
Please include copies of the following.
CME exam (if available)