CFTSS Referral Form

Email: cftssintake@jemcare.org

Phone: 929-469-5720
Children and Family Treatment and Support Services (CFTSS) Referral Form
DATE OF REFERRAL

MonthDayYear
INSTRUCTIONS: This form must be completed in its entirety to allow JEMCare to verify eligibility for services.
Member's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Assigned Sex at Birth*
Preferred Gender
Pronouns
Medical Coverage*
Medicaid ID*
Insurance Name*
Insurance ID*
Preferred Language
If Others, please specify
Phone*
Format: (000) 000-0000.
Email
Address*
City*
State*
Zipcode*
CONSENT AND CONFIDENTIALITY
Has consent been obtained from the Parent/ Guardian/ Legally Authorized Representative for this referral?*

YesNo
Parent/Guardian's Name*

First NameLast Name
Relationship to Member*
Preferred Language
If Others, please specify
Is Member in Foster Care?*

YesNo
Note any confidentiality concerns or treatment preferences (If the client has no preferences, please write N/A)
Child / Family Availability for Intake Call (Please include Days and Times i.e. Monday 2pm-5pm)
REFERRAL SOURCE INFORMATION
How was this referral being made?*
Name of Referrer*
Relationship to Referent*
Organization/Agency*
Role/Job Title*
Referrer Phone*
Format: (000) 000-0000.
Referrer Email
REASONS FOR REFERRAL
Primary Concerns (Check all that apply)*

Behavioral IssuesSchool-Related IssuesTrauma ExposureEmotional DistressFamily ConflictOther
Symptoms of Concern (Check all that apply)*

DepressionEncopresisAnxietyDevelopmental DelaysPhobiaHyperactivityDanger to SelfAttention DeficitsSuicidal Ideation(s)ImpulsiveSelf-InjuryRunawayDanger to Other(s)Negative Peer InteractionsTemper TantrumsPhysical AggressionSleepVerbal AggressionEating DisturbanceProblematic Social BehaviorEnuresisSexually AggressiveAlcohol UseSexually InappropriateDrug UseOther
Any known safety concerns*
If Yes, please specify*
Does the member have a verified diagnosis and/or Individualized Education Plan (IEP) ?*
If Yes, please specify*
Please attach documentation for verified diagnoses and/or IEP*

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SERVICES
Services being requested

Other Licensed Practitioner (OLP)Community Psychiatric Supports and Treatment (CPST)Psychosocial Rehabilitation (PSR)Family Peer Support Services (FPSS)Youth Peer Support and Training (YPST)
Has the child/family received any CFTSS services previously?

YesNo
Were services received in last 6 months?*
Service Provider*
Type of Service/s*
CURRENT SUPPORT SYSTEM
Is the child/family currently receiving support from any services, such as Health Home Care Management (Care Management) or Home and Community Based Services (HCBS)?

YesNo
Agency Name*
Type of Support*
Contact Person*
Contact Information*
If no, would the child/family like to explore receiving these services?*
Upload any additional documents or supporting materials relevant to the referral

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Children and Family Treatment and Support Services (CFTSS) Referral Form

CONSENT AND CONFIDENTIALITY

REFERRAL SOURCE INFORMATION

REASONS FOR REFERRAL

SERVICES

CURRENT SUPPORT SYSTEM