Service Order
The Family Center, LLC
Case Number: ________________________Case Name: _____________________________
Date: _____________________________ Service Order Number ______________________
Client’s Name: _________________________________________________________________________
Client’s Address: _______________________________________________________________________
______________________________________________ Phone __________________
Caseworker’s Name: ___________________________________________________________________
Caseworker’s Contact Phone: _______________________________ Pager: _____________________
Supervisor’s Name: ____________________________________________________________________
Supervisor’s Contact Phone: _________________________________Pager: _____________________
Services to be provided: Funding Source:
______ Family Assessment ______ PUP
______ Crisis Intervention ______ Special PA Project
______ Intensive Family Therapy ______ Homestead
______ Domestic Violence Group ______ Client Self Pay
______ Sex Offender Groups/Assessment ______ Wrap Around
______ Parent-Aide Services Maximum Expenditure
______ Parenting Group $ ___________________
______ Anger Management Group
______ Domestic Violence Group
______ Sex Offender Groups/Assessment
______ Other (specify) __________________________________________________________________
__________________________________________________________________
Services shall begin on _________________ Service shall end on _________________________
Reason for Intervention _________________________________________________________________
_____________________________ ____________________________
Caseworker Date Supervisor Date
____________________________________________________
Administration Title Date
1117 Georgia Avenue, Suite D 632 Fifth St
North Augusta, South Carolina 29841 Augusta, Ga 30901
803 278 4708 (office) 706 828 4855
803 202 0360 (fax)
Additional Notes: _________________________________________________________
