Circle of Care Referral Form
Date of Referral:
*
-
Month
-
Day
Year
Date
Youth Name:
*
First Name
Last Name
Youth's Date of Birth:
*
-
Month
-
Day
Year
Date
Affirmed/Preferred Name:
*
Medicaid ID #:
*
Language Required for Services:
*
Sex:
*
Age (3-17):
*
Indicate Payer Type:
*
Guardian's Name:
*
First Name
Last Name
Guardian's Relationship to Youth:
*
Guardian's Phone Number:
*
Please enter a valid phone number.
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent(s) Name if Different:
Members of the Household:
*
Referent Name:
First Name
Last Name
Referring Agency:
Referent Phone:
Please enter a valid phone number.
Referent Email:
example@example.com
Has the family voluntarily agreed to this referral?
*
Yes
No
Please list all Psychiatric Hospitalizations, Crisis Visits, or Risk Assessments that have occurred in past (1) one year:
*
Re-Risk for Hospitalization 1 2 3 4 5 (1=Very Low, 3=Moderate, 5=Very Likely):
*
1 - Very Low
2
3 - Moderate
4
5 - Very Likey
Current Diagnoses:
*
Other Child and Family Team Members (DCFS, Foster Care, Psychiatry, Individual Therapist, etc.):
Reason for Referral/Goals (symptoms, behavioral/social/emotional functioning of youth, family, focus of treatment):
*
Current Medication
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Services Being Requested (Check All That Apply):
*
In-Home Therapy (IHT)
Youth Community Mentor (YCM)
Family Community Mentor (FMC)
Preference for Location of Services:
*
Chicago
Springfield
Family's Preference for Scheduling Days:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Family's Preference for Scheduling Times:
At-Risk Factors or Safety Concerns Present (check all that apply)
*
Suicidal Ideations
Suicidal Gestures
Self-Injurious Behaviors
Homicidal Ideations
Current Substance Use
History of Substance Abuse
Runs Away
Violence/Aggression Towards Others
Takes Dangerous Risks
School Refusal
Lack of Social Group
Gang Involvement
Med Compliance Issues
Fire Setting
High Risk Sexual Activity
Isolates
Sexualized Aggression and/or Behaviors
Trauma History (explain below)
Medical/Physical Issues (explain below)
Other
Explain Trauma History:
Explain Medical/Physical Issues:
Caregiver Risk Factors:
Current Substance Abuse
History of Substance Abuse
Med Compliance Issues
Financial Distress
Housing Instability
Current or History of Domestic Violence
Unable or Unwilling to Provide Supervision
Lack of Natural Supports
Medical/Physical Issues (explain below)
Other
Caregiver Risk Factors - Identify which Caregiver:
Explain Medical/Physical Issues:
Explain Other Caregiver Risk Factors:
Safety Concerns for Home-Based Team to Plan for (Check all that Apply):
Unsafe Neighborhood
Current Domestic Violence
Violent Family Member of Person Involved with Family
Lack of Safe Parking Available
Animals (List below for allergies)
Suspected Illegal Substances in Home
Weapons in Home
List of Animals in Home:
* Please Note: All referrals will be responded to within 1 business day
Submit
Should be Empty: