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)