CAC Referral Form

Child/Youth Information:
Child/Youth Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Child/Youth Address
Child/Youth Phone

Area CodePhone Number
Is it okay to leave a voicemail at this number?

YesNo
Child/Youth Email*
example@example.com
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone

Area CodePhone Number
Parent/Guardian Email
example@example.com
Insurance Provider:

MedicaidCommercialNone
Provider One or Subscriber Number
Company Name:
(Example: Regence, Tricare, etc.)
Tribal Connection

YESNOUnknown
Juvenile Justice Involvement

YESNOUnknown
Department of Children, Youth and Families (DCYF) Involvement:

YESNOUnknown
Special Education

YESNOUnknown
Enrolled in Developmental Disabilities Administration (DDA):

YESNOUnknown
In Utero Substance Exposure:

YESNOUnknown
Intellectual or Developmental Disability:

Autism Spectrum DisorderOther I/DDNeeds AssessmentNone
Adoption Status

NoneWashington State AdoptionOut of State AdoptionPrivate Adoption
Age of Onset of Symptoms
I would like to consult with the Team About:

Outpatient Service Navigation: I am looking for recommendations regarding outpatient mental health and/or substance use disorder treatment resources.Care Coordination Needs: I am looking for assistance with care coordination for a youth enrolled in various services or multiple system involvement (Juvenile Justice, Behavioral Health, Foster Care, etc.)Behavior Management Strategies: I am looking for recommendations for behavioral management strategies to support safety within the communityTransitional Planning: I have a child/client who is transitioning back into the community from placement (inpatient unit, CLIP) who needs additional supports or recommendations for transitioning back into the communityDischarge Planning: I need assistance with developing a discharge plan from an Emergency DepartmentFamily Engagement Ideas: I need assistance with engaging a family in services or to address barriers in access to servicesSafety Planning: I am a provider who would like consultation to complete a safety planOther
Referent Information:
Name of Person Making the Referral*

First NameLast Name
Name of Clinic / Hospital / Organization*
Phone Number

Area CodePhone Number
Referent Email*
example@example.com
Reason for Referral:
Briefly, provide information as to reason for referral and expected outcomes
To maintain the privacy of youth and family a release of information (ROI) is required. A Release of Information is required to be signed by youth over the age of 13. Do you currently have a signed Release of Information (ROI)?

YesNo
A RELEASE OF INFORMATION form should accompany each referral request.
How did you hear about Kids’ Mental Health Pierce County?

A Friend or Family MemberA ProviderOnline SearchSocial MediaFlyer/PrintOther
If you have additional questions please contact Ashley Mangum at amangum@multicare.org
Should be Empty:

Child/Youth Information:

Referent Information: