Level III referrals require submission of a psychosocial evaluation dated within 30 days of submission of the referral. This document can be uploaded with this referral. This evaluation must have an assignment of a Diagnostic and Statistical Manual (DSM) diagnosis or Diagnostic Criteria 0-5 (DC 0-5) and address the following:
I. Identifying information.
II. Reason for referral.
III. Reports reviewed to complete this referral.
IV. Risk of Harm - Indicate child’s or youth’s potential to be harmed by others or cause significant harm to self or others.
V. Functional Status - Indicate the degree to which the child or youth is able to fulfill responsibilities and interact with others. Include educational.
VI. Co-Occurrence of Conditions - Developmental, medical, substance use, and psychiatric. Include DSM 5 diagnosis and medications, both current and past.
VII. Recovery Environment - Indicate environmental factors that have the potential to impact the child’s or youth’s efforts to achieve or maintain recovery. Include description of family constellation and commitment.
VIII. Resiliency and/or Response to Services - Indicate the child’s or adolescent’s ability to self-correct when there are disruptions in the environment. Include any major life changes and how the child or adolescent responded.
IX. Involvement in Services - Indicate the quantity and quality of the child’s/youth’s and primary care taker’s involvement in services. Include involvement with other agencies; list all inpatient and outpatient treatments, and out-of-home placements (i.e., group homes, shelters, foster care, or RTCs).