Referral Form

Referral Form for Sex Offender Specific Evaluations

Heather Wilkerson, MSW, LCSW

(910) 494-5888

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Court Counselor’s Name:

 

Court Counselor’s Phone Number:

 

Court Counselor’s Email Address:

 

Client’s Next Court Date:

 

Client’s Name:

 

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 Address:

 

Client’s legal guardian’s name?

 

Client’s legal guardian’s phone number?

 

Please include copies of the following.

 

Court Order

 

Social History

 

Police Report

 

Victim’s Statement

 

CME exam (if available)


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