Referral Form
Children's Health Home Services
Who is completing this form?
*
Parent/Guardian/Legally Authorized Representative
Liberty Resources Employee
Other Supporter
Name of Parent/Guardian/Legally Authorized Rep completing this form.
First Name
Last Name
County Residence
*
Please Select
Cayuga
Dutchess
Madison
Monroe
Oneida
Onondaga
Orange
Oswego
Rockland
Westchester
Name of Youth
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Youth's DOB
*
-
Month
-
Day
Year
Date
Gender Identity
*
Is the youth currently in Foster Care?
*
Please Select
Yes
No
Unknown
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Insurance Information
What type of insurance is the youth covered under?
Medicaid/Child Health Plus
Private Insurance
Medicaid CIN# (ex:AB12345C)
Managed Care Organization
Insurance Carrier
Policy #
Subscriber's Name
First Name
Last Name
Subscriber's DOB
-
Month
-
Day
Year
Date
Subscriber's relationship to youth
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Consent to Refer
Who has provided you with consent to make this referral?
Parent
Guardian
Legally Authorized Representative
Child/Youth who is 18 years or older
Child/Youth who is a parent
Child/Youth who is pregnant
Child/Youth who is married
Consenter Information
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Child
Is the youth's parent/guardian currently enrolled in a health home program?
Yes
No
Contact Information for Referral Source
Name
First Name
Last Name
Title
Organization
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you able to provide proof of eligibility?
Yes
No
Does the child need to be assessed for HCBS?
Yes
No
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Eligibility Criteria
Youth may be eligible by having two or more chronic health conditions or one of the following single qualifying conditions: HIV/AIDS, Serious Emotional Disturbance, Complex Trauma.
To the best of your knowledge, what chronic conditions, mental health diagnosis or complex trauma make the child eligible for NYS Health Home services?
Reason for referral
RISK FACTORS: Check all that apply
Needs connection to medical providers.
Needs support to avoid out of home placement and/or hospitalization.
Needs help connecting with social/family/housing supports.
Requires support and advocacy with medical care.
Recently released from incarceration, placement, detention, or psychiatric hospitalization.
Has deficits in activities of daily living, learning or cognition issues.
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