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

Other
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
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
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
Format: (000) 000-0000.
Additional Contact Email
example@example.com
Addtional Contacts Relationship to Youth
Is child in DFCS Custody?
DFCS Case Worker Name

First NameLast Name
DFCS Case Worker Primary Phone #
Format: (000) 000-0000.
DFCS Case Worker Email
example@example.com
Select Referral Source
Name of Referring Individual

First NameLast Name
Referrer Phone #
Format: (000) 000-0000.
Referrer Email
example@example.com
Select Agencies Currently Involved

Other
Behavioral Health Provider Agency Name:
Contact Name:

First NameLast Name
Contact Phone Number:
Format: (000) 000-0000.
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?
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

Other
Please provide details for any presenting circumstance/risk listed above occurring within the last six months
Emotional/Behavioral Needs

Other
Past/Current exposure to Potentially Traumatic/Adverse Childhood Experiences

Other
Life Functioning Needs

Services Received by the Youth in the past twelve months

Rows	# 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?
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?
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?
If yes, please upload supporting documentation

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