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Child & Family Treatment and Support Services
Date of Referral
*
/
Month
/
Day
Year
Date
Which Services are you interested in?
Please Select
CFTSS services only: OLP, CPST, FPSS and PSR
Functional Family Therapy (FFT) only
CFTSS and FFT services
OLP only
CPST only
PSR only
FPSS only
Choose which service you would like the youth to be referred for. If it is a combination of CFTSS services please choose that
Name
*
Please enter the name of the person you are referring to CFTSS Services.
Sex
*
Please Select
Female
Male
Unknown
Please select the youth's gender.
Preferred Pronouns
Please Select
She / Her
He / Him
They / Them
Other
Select the youth's pronouns.
Date of Birth
*
/
Month
/
Day
Year
Date
Medicaid #
*
Input the youth's Medicaid #.
MCO
*
Please Select
Unknown
Fidelis
Molina
Blue Choice (Excellus)
MVP
Optum
Medicaid
Medicaid Company
MCO Policy #
Primary Language
*
Race
*
Please Select
Unknown
American Indian
Alaska Native
Asian
Multi-Racial
Black/African American
White-Hispanic
White- Non-Hispanic
Ethnicity
*
Please Select
Unknown
Hispanic/Latinx
Not Hispanic/Latinx
School Attending
*
Grade Level
*
Does the youth have an IEP or 504?
*
Please Select
Yes
No
Unknown
Parent/Guardian(s) name
*
Relationship to Youth
*
Phone Number
*
Phone Number of Parent/Guardian 1
Name of Person or Type of Phone Number (mobile / home / etc)
Parent/Guardian email
*
example@example.com
Other Phone Number
Please enter a valid phone number.
Name of Person or Type of Phone Number (mobile / home / etc)
Other Email
*
example@example.com
Address, City, State & ZIP Code
*
Residence type
*
Please Select
Home-Rent
Home-Own
Apartment
Shelter
Hotel/Motel
Unknown
County
*
Please Select
Onondaga
Oswego
Mental Health/SED Diagnosis
If available, please provide diagnosis.
Diagnosed by
Provide name of medical professional who provided diagnosis.
Date of Diagnosis
/
Month
/
Day
Year
Date
Medical Diagnosis
Date of Diagnosis
/
Month
/
Day
Year
Date
Allergies
Contacts
Name
Phone
Agency
Email
Perfon Completing Referral
Referral Source
Primary Care Physician
Mental Health Provider
Psychiatrist
Care Manager or C‐YES
School Contact
Reason for Referral
*
Challenging Interpersonal Relationships
Trauma or PTSD
Safety Concerns
Foster Child with recent/multiple placements
Medically Fragile
Challenges in Family System
Attachment Issues
Aggression
Drug/Substance/Alcohol Use
Runaway Behaviors
History of Out of Home Placement
School Refusal or Elopement
Current out of home placement
Law Enforcement Contact/Probation
Other
Safety Concerns
Suicidal Ideation/attempt
Self Harm
Homicidal Ideation/attempt
Sexual Behaviors/Reactivity
Aggression
Home
School
Community
Type of Trauma or Event for PTSD
Last Suicidal Ideation/Attempt Date
Last Self-Harm Event
Last Homicidal Ideation/Attempt Date
Last Sexual Behavior/Reactivity Event Date
Medical Fragile:
Drug/Substance/Alcohol Use:
Other Explanation:
Submit
Should be Empty: