WinGeorgia/LMCME IC3 Referral Form

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 Acceptance Information:
- Youth with Severe Emotional Behavioral Health Diagnosis
- Ages 6-18
- Youth with high risk within past 6 months for self-harm, suicidal behaviors, homicidal behaviors, and other high risk behaviors, such as sexual offense, runaway, fire setting, property destruction, imminent risk of out of home placement
- Placed out of home at least once within the past year
- We are not able to accept commercial insurance referrals
- We do not accept referrals with primary feature of developmental disability (such as Autistic Spectrum Disorder) or Conduct Disorder.
Referral Date

MonthDayYear
Date
Youth Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Birth Gender
Gender Identity
Race*
Primary Language*
School Currently Attending*
School Grade Level
School Services*

IEP504 PlanNoneOther
Primary Insurance Carrier*
Primary Insurance Policy Number*
If Primary Ins is Medicaid - please document Medicaid # here
Secondary Insurance Carrier
Secondary Insurance Policy Number
If Primary Ins is Medicaid - please document Medicaid # here
Parent/Guardian's Name*

First NameLast Name
Relationship to Youth*
Phone Number *
Secondary Phone Number
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County of Residence*
Additional Contact Name:

First NameLast Name
Additional Contact Phone Number
Additional Contact Email
example@example.com
Addtional Contacts Relationship to Youth
Is child in DFCS Custody?*

YesNo
DFCS Case Worker Name

First NameLast Name
DFCS Case Worker Primary Phone #
DFCS Case Worker Email
example@example.com
Select Referral Source*
Name of Referring Individual*

First NameLast Name
Referrer Phone #*
Referrer Email*
example@example.com
Select Agencies Currently Involved*

Enrolled in School (check if YES)Inpatient HospitalPRTF (Residential Facility)Child Caring Inst. (Group Home)Dept. of Juvenile JusticeDBHDD Core ProviderPrivate Provider or PediatricianJuvenile CourtDFCS (non-custody only)DFCS Custody (GA Families 360)Family Support OrganizationLaw EnforcementCrisis Stabilization UnitGeorgia Cares (CSEC)Other
Behavioral Health Provider Agency Name:
Contact Name:

First NameLast 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?*

YesNo
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-HarmSuicidal ThoughtsSuicidal AttemptHomicidal Thoughts/BehaviorsSexual AggressionDelinquent BehaviorIntentional BehaviorsFire setting/Property DestructionRunawayThreats of ViolenceActive Substance UseImminent risk of out-of-home placementOther
Please provide details for any presenting circumstance/risk listed above occurring within the last six months*
Emotional/Behavioral Needs*

PsychosisAttention/ConcentrationImpulsivityDepressionAnxietySubstance AbuseAttachment DifficultiesAnger ControlPTSDPhobiasObsession/CompulsionOppositionalConductAdjustment to TraumaOther
Past/Current exposure to Potentially Traumatic/Adverse Childhood Experiences*

Sexual AbusePhysical AbuseEmotional AbuseNeglectWitness to Family ViolenceCommunity ViolenceSchool ViolenceParental Criminal BehaviorDisruptions in Caregiving/Attachment LossesOther
Life Functioning Needs*

FamilyLiving SituationSocial FunctioningLegalSleepRecreationalSchool BehaviorSchool AttendanceDecision MakingSchool AchievementRecreationalDevelopmentalRecreationalJob FunctioningLegalMedical/PhysicalSexual 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?*

YesNo
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?*

YesNo
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?*

YesNo
If yes, please upload supporting documentation

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WinGeorgia /Care Management Entity Intensive Customized Care Coordination High Fidelity Wraparound (IC3) Referral