CK Behavioral Health Referral Form

Child/Youth Information
Child/Youth Name*

First NameLast Name
Child/Youth DOB*

MonthDayYear
Placed in foster care or kinship care?*

YesNo
Insurance/Medicaid Plan*
Insurance/Medicaid ID Number*
Child/Youth Current Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence*
Is the child/youth currently receiving mental health or behavioral health services?*

YesNo
Current Provider List:*
Please type the name(s) of current mental health and behavioral health providers and the services the child/youth is receiving from that provider. (example: Tarrant County MHMR). If No, please type "N/A".
Reason for Referral*
Briefly describe the reason(s) you are making this referral; list specific behaviors, emotions, or symptoms the child is displaying.

Legally Authorized Representative (LAR) Information

Parents, Foster Parents, Medical Consenter, Other Legal Guardian
LAR Relationship to Child/Youth*

Parent or GuardianFoster ParentKinship Caregiver
LAR Name*

First NameLast Name
LAR Phone Number*
Please enter a valid phone number.
LAR Email*
example@example.com
Should be Empty:

Child/Youth Information