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Referral Form
1
Step 1
Complete Online and submit.
Call 270-444-3650 if have questions.
Child's Name
Sex
Choose One
Male
Female
Date of Birth
date_range
Child's SSN
Insurance:
Aetna MCO
Anthem MCO
Well Care
Humana MCO
Passport
Private
Other
Other Insurance Name
Is Your Child Diagnosed with Any Physical Health Condition?
Select An Option
Yes
No
If Yes, Please Specify:
0
/
Guardian's Name
Phone Number
Live With:
Select An Option
Yes
No
Guardian Relationship
Select An Option
Parent
Grandparent
Aunt/Uncle
DCBS Custody
Other
Please Specify:
Child's Street Address
State
Select An Option
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Has Guardian Participated in IMPACT Referral?
Yes
No
Parental Signature
(Sign Here)
Clear Signature
School
Grade
IQ:
Does Child Have an IEP or Receive Special Education Services?
Yes
No
Current Education Placement
Select An Option
No Special Placement
Homebound
Suspension
Alternative School
Day TX
Has Child Had Residential/Hospitalization Placement
Yes
No
Most Recent Admission Date?
date_range
Most Recent Discharge Date?
date_range
Where?
Type of Placement?
Short Term Care
Partial Program
Long Term/Extended Care
Is Child in Counseling?
Yes
No
Where?
With Whom?
Does Child have a Mental Health Diagnosis?
Yes
No
Please Elaborate:
0
/
Is Child on Medication for Emotional, Behavioral, or a Psychiatric Disorder/Diagnosis?
pick one!
Yes
No
Please List ALL Medication, Dosage and Prescribing Doctor:
0
/
Has Child ever been the victim of/perpetrator of sexual abuse/physical abuse or neglect?
Yes
No
By Whom/Toward Whom?
Does Child have a history of using/abusing alcohol or drugs?
Yes
No
Please Describe
0
/
Is Child currently involved with:
Check all that apply
None
CDW's Office
Dept. of Juvenile Justice
FRBH
DCBS-Protection & Permanency
School
Day Care
Other
Other:
Reasons for Referral (Check all that Apply for problematic behaviors over last year):
Disciplinary Referrals
Difficulty with Peer Relations
Requires Frequent Discipline
Seeks Negative Peers
History of School Suspension
Social Withdrawal/Isolation
Defies Adults Requests
Runs Away
Physical Aggression
Social Delays
Noncompliant w/ Chores
Unusual Behaviors
Verbal Aggression
Sadness/Depression
Tearful
Soils Clothes
Destruction of Property
Grief (Death/Divorce)
Tantrums
Bed Wetting
School Truancy
Poor Hygiene
Hallucinates
Explosive Behavior
Theft
Cruelty to Animals
Irritability/Mood Swings
Low Self Esteem
Dishonesty
Sensory Problems
Sleeping Difficulties
Multiple Day Care Moves
Defiant Behavior
Appetite Problems
Difficulty w/ Sibling Relations
Compulsivity
Over-Activity
Learning Difficulties
History of Vandalism
Impulsivity
Poor/Declining Grades
Sexually Promiscuous
Inattention
Self-Harming Behavior
Involvement w/ a Cult/Gang
Unusual Fears or Anxiety
Suicide Attempts
Fire Setting Behavior
Other
Describe Other:
0
/
What benefits do you hope child/family will gain from involvement with IMPACT? (Be specific)
0
/
Person/Agency Making Referral:
Address:
Phone Number:
Date of Referral:
date_range
CASII or ECSII Score:
Level:
Referral will not be processed until the CASII or ECSII Score and Level are received.
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