WinGeorgia /Care Management Entity Intensive Customized Care Coordination High Fidelity Wraparound (IC3) Referral
Complete all required questions and click "Submit" to send a referral to WinGeorgia
Referral Age Range Information:
For State Funded Youth we accept referrals for ages 6 - 20 // For CMO Youth we accept referrals for ages 6-18
Referral Date
-
Month
-
Day
Year
Date
Youth Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Birth Gender
Please Select
Female
Male
Gender Identity
Please Select
Identifies as Male
Identifies as Female
Female-to-Male (FTM)/Transgender Male/Trans Man
Male-to-Female (MTF)/Transgender Female/Trans Woman
Genderqueer, neither exclusively male nor female
Choose not to disclose
Additional gender category or other, please specify
Race
*
Please Select
American Indian/Alaskan Native
Asian-Other
Black/African-American
Latino-Hispanic
Latino-Non-Hispanic
Pacific Islander
Multiracial
White/Caucasian
Other Single Race
Unknown/Not Indicated
Primary Language
*
Please Select
English
Spanish
French
German
Mandarin
Portuguese
Tagalog
Italian
Polish
Not Specified/Unknown
School Currently Attending
*
School Grade Level
Please Select
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
School Services
*
IEP
504 Plan
None
Other
Primary Insurance Carrier
*
Medicaid
Amerigroup
WellCare
PeachState/Cenpatico
CareSource
Private/Commercial
Primary Insurance Policy Number
*
If Primary Ins is Medicaid - please document Medicaid # here
Secondary Insurance Carrier
Medicaid
Amerigroup
WellCare
PeachState/Cenpatico
CareSource
Private/Commercial
Secondary Insurance Policy Number
If Primary Ins is Medicaid - please document Medicaid # here
Parent/Guardian's Name
*
First Name
Last Name
Relationship to Youth
*
Please Select
Parent
Guardian
Foster Parent
Phone Number
*
Secondary Phone Number
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
State
Zip Code
County of Residence
*
Additional Contact Name:
First Name
Last Name
Additional Contact Phone Number
Additional Contact Email
example@example.com
Addtional Contacts Relationship to Youth
Please Select
Parent
Guardian
Foster Parent
Is child in DFCS Custody?
*
Yes
No
DFCS Case Worker Name
First Name
Last Name
DFCS Case Worker Primary Phone #
DFCS Case Worker Email
example@example.com
Select Referral Source
*
Please Select
Parent/Guardian
Inpatient Hospital
Residential Facility (PRTF)
DJJ In Community
DJJ Secure Facility
DBHDD Core Provider
Private Provider or Pediatrician
Juvenile Court
DFCS Family Preservation
DFCS Custody (GA Families 360)
System of Care (LIPT/CHINS/CSEC)
School System
Crisis Stabilization Unit (CSU)
Family Support Organization
Name of Referring Individual
*
First Name
Last Name
Referrer Phone #
*
Referrer Email
*
example@example.com
Select Agencies Currently Involved
*
Enrolled in School (check if YES)
Inpatient Hospital
PRTF (Residential Facility)
Child Caring Inst. (Group Home)
Dept. of Juvenile Justice
DBHDD Core Provider
Private Provider or Pediatrician
Juvenile Court
DFCS (non-custody only)
DFCS Custody (GA Families 360)
Family Support Organization
Law Enforcement
Crisis Stabilization Unit
Georgia Cares (CSEC)
Other
Behavioral Health Provider Agency Name:
Contact Name:
First Name
Last Name
Contact Phone Number:
Contact Email:
example@example.com
Mental Health Diagnosis:
*
Substance Abuse Diagnosis:
Developmental/IDD Diagnosis:
Current Medication(s)
Do you have a GA CANS you are able to share with us?
*
Yes
No
If Yes to CANS, please attach copy of most recent CANS
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Please provide a brief youth/family history
*
Describe challenges the youth is having
*
(i.e. at home, in school, and in the community)
What are the current stressors in the home environment?
*
Stressors could be home, school, work... that interferes with well-being of youth.
Response to current treatment
*
Presenting Circumstances/Risks
*
Self-Harm
Suicidal Thoughts
Suicidal Attempt
Homicidal Thoughts/Behaviors
Sexual Aggression
Delinquent Behavior
Intentional Behaviors
Fire setting/Property Destruction
Runaway
Threats of Violence
Active Substance Use
Imminent risk of out-of-home placement
Other
Please provide details for any presenting circumstance/risk listed above occurring within the last six months
*
Emotional/Behavioral Needs
*
Psychosis
Attention/Concentration
Impulsivity
Depression
Anxiety
Substance Abuse
Attachment Difficulties
Anger Control
PTSD
Phobias
Obsession/Compulsion
Oppositional
Conduct
Adjustment to Trauma
Other
Past/Current exposure to Potentially Traumatic/Adverse Childhood Experiences
*
Sexual Abuse
Physical Abuse
Emotional Abuse
Neglect
Witness to Family Violence
Community Violence
School Violence
Parental Criminal Behavior
Disruptions in Caregiving/Attachment Losses
Other
Life Functioning Needs
*
Family
Living Situation
Social Functioning
Legal
Sleep
Recreational
School Behavior
School Attendance
Decision Making
School Achievement
Recreational
Developmental
Recreational
Job Functioning
Legal
Medical/Physical
Sexual Development
Services Received by the Youth in the past twelve months
*
# of admits/stays
Inpatient Hospital
Residential Treatment Facility
DFCS/CCI/CPA
DJJ
Juvenile Court
RYDC
Youth Development Center
Crisis Stabilization Unit
Other
Has youth/family been presented at LIPT or CHINS?
*
Yes
No
If yes, Team Recommendation:
Has the parent/guardian been informed about services provided by WinGeorgia CME and provided consent for this referral to be placed?
*
Yes
No
Do you have the following information: Diagnosis verification, Behavioral Health Assessment, CSU/PRTF discharge papers, Psychological, DR. Apt note, CANS, and copy of Insurance cards?
*
Yes
No
If yes, please upload supporting documentation
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