Monday - Friday9AM - 5PM

Office 1180 US-51 Suite A, Ponchatoula, LA 70454

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FORMSReferral Form

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REFERRAL FORM

Submit your Referral Form

Functional Family Therapy (FFT) is an intensive, evidence-based program to address complex issues for children and adolescents, aged 10-18 years, who have been referred for emotional and behavioral problems. FFT is home community-based and uses a systematic approach to assist the family with changing maladaptive behaviors.

Youth's Name*

Birthdate*

Age (must be between 10-18)*

Gender*
MaleFemaleOther

Permission to Leave a Message (Home/Cell)*YesNo

Permission to Leave a Message (Work)*YesNo

Permission to Leave a Message (Alternate)*YesNo

Best contact time*Morning(8AM-11AM)Afternoon(noon-3PM)Evening(4PM-7PM)Anytime

Presenting Problems*Behavioral Concerns at Home/SchoolDepression/Self-Esteem/CuttingLife Issues/ProblemsFamily Conflict/Relationship ProblemsPhysical AggressionTraumaAnxietyParentingSubstance AbuseOther

Has the client been diagnosed with a behavioral or mental health disorder in the past? If yes, previous diagnosis?

Referral Source Name*

The journey to better mental and emotional health is not always easy but it is well worth it in living your best life.

Home and community-based program serving: (Livingston, Tangipahoa, & St. Tammany)

jccsadmin@journeyccservices.com

1180 US-51 Suite A, Ponchatoula, LA 70454

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Home
About Us
Our Team
Join Our Team
Resources
Contact

Services

Individual Therapy/Counseling
Functional Family Therapy (FFT)

Forms

Referral Form
Client Survey
Stakeholder Survey

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