PRIDE CFTSS Referral Form
Date:
*
-
Month
-
Day
Year
Date
Youth Legal Name:
*
First Name
Last Name
Affirmed/Chosen Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Age (3-21):
*
Gender Identity:
*
Man or Boy (cis)
Woman or Girl (cis)
Transgender Man or Boy/Trans Man/Masculine
Transgender Woman or Girl/Trans Woman/Feminine
Genderqueer/Gender Expansive/Nonbinary/Neither exclusively male nor female
Gender Not Listed Above
Pronouns:
*
He/Him
She/Her
They/Them
Pronouns not listed above
Primary Language:
*
Preferred Language:
*
Medicaid ID #:
*
Payer Type:
*
Guardian(s) Name:
*
First Name
Last Name
Guardian (s) Preferred Language:
*
Relationship to Youth:
*
Parent Name (if different):
*
First Name
Last Name
Guardian's Phone Number:
*
Please enter a valid phone number.
Guardian's Email:
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Members of Household:
*
Referent Name:
*
First Name
Last Name
Referring Agency:
*
Referent Phone Number:
*
Please enter a valid phone number.
Referent Email:
*
example@example.com
Has a CFTSS referral been placed to another agency at the same time?
*
Yes
No
If Yes, Which Agencies:
Has the client received CFTSS or HCBS services previously?
*
Yes
No
If Yes, Which Agency? When? Reason for Termination:
Has the family voluntarily agreed to this referral?
*
Yes
No
Please list all Psychiatric Hospitalizations, Previous Mental Health Diagnosis, Crisis Visits, or Risk Assessments that have occurred in the past (1) one year:
*
Risk for Re-Hospitalization (1= very low, 3=moderate, 5=very likely):
*
1
2
3
4
5
Other Current Providers (ACS, Preventive Services, Foster Care, Psychiatry, etc.) - Please Include Name, Service Agency and Phone Number:
Current Struggles and Goals (Symptoms, Behavioral/Social/Emotional Functioning of Youth and or Family, Focus of Treatment):
Preferred Therapist:
*
He/Him
She/Her
They/Them
No Preference
Service Being Requested (Check All that Apply):
*
CFTSS: OLP (Other Licensed Practitioner)
CFTSS: PSR (Psychosocial Rehabilitation)
CFTSS: YPSS (Youth Peer Support Services)
CFTSS: CPST (Community Psychiatric Support and Treatment)
CFTSS: FPSS (Family Peer Support Services)
Reason CFTSS Level of Care needed (please choose all that apply):
*
Outpatient services alone are not sufficient to meet youth and family's needs for clinical intervention
Need for increased frequency/duration/flexibility of family sessions depending on need in the home and community
Need for 24/7 urgent telephonic response and risk management/safety planning
Youth at risk for out-of-home placement
Need for care coordination with school, other providers, state agencies, natural supports, etc.
Need treatment to enhance youth's problem-solving, limit setting, and communication to sustain youth in home
Strengthen caregiver(s) ability to sustain youth in home
High level of risk factors (indicate below)
At-Risk Factors of Safety Concerns Present (please choose all that apply):
*
Suicidal Ideations
Suicidal Gestures
Self-Injurious Behaviors
Homicidal Ideations
Current Substance Use
History of Substance Abuse
Running Away
Violence/Aggression towards others
Lack of Social Group
Isolates
School Refusal
Gang Involvement
Sexualized Aggression and/or Behavior
High Risk Sexual Activity
Takes Dangerous Risks
Fire-Setting
Med Compliance Issues
Other
Explain Youth Medical/Physical Issues, Trauma History or Other At-Risk Factors Present:
Caregiver Risk Factors (please choose all that apply):
*
Current Substance Use
History of Substance Abuse
Med Compliance Issues
Housing Instability
Financial Distress
Current Domestic Violence
History of Domestic Violence
Unable/Unwilling to Provide Adequate Supervision
Lack of Natural Supports
Mental Health Diagnoses - In Treatment? (please explain below)
Medical/Physical Issues (please explain below)
Other (please explain below)
None
Explain Caregiver Mental Health Diagnoses (include if in treatment), Medical/Physical Issues or Other At-Risk Factors Present:
Identify which Caregiver the At-Risk Factors apply to:
Safety Concerns for Home-Based Team to Plan For (please choose all that apply):
*
Unsafe Neighborhood
Current Domestic Violence
Violent Family Member or Person Involved with Family (please describe below)
Lack of Safe Parking Available
Animals
Suspected Illegal Substances in Home
Weapons in Home
None
Provide details on Violent Family Member or Person Involved Involved with Family:
What Animals are in the Home?
Submit
Should be Empty: