Family Based Mental Health Services (FBMHS) Referral Form

Bedford, Cambria & Somerset Counties

Childs Name

Date of Birth

Date

Gender

Race

Address

Social Security Number

Insurance

County

MA Number

Referral Source

Contact Person

Phone

Psychiatrist/Psychologist

Phone

Secondary Phone

GAF

Outpatient MH treatment is inappropriate or insufficient to meet the needs of the CHILD because must be completed

Suicidal/homicidal ideation/self-injurious behavior Impulsivity and/or aggression

Affection/function impairment (i.e. withdrawn, reclusive, labile) Psychomotor retardation or excitation

Psychosocial functional impairment Thought impairmentSED*** If present, describe in detail below:

Name

DOB

MA

SELECTION ELEMENT NOTSELECTED Psychophysiological condition ( ie bulimia anorexia nervosa)

Psycho-physiological condition (i.e., bulimia, anorexia nervosa)

Is child at risk for out-of-home placement? (Yes/No) If yes, explain:

Has the child ever been placed out of the Home? (Yes/No)If yes, explain:

At risk for what type of out-of-home placement? Psychiatric hospitalization Foster care Juvenile Court Placement Other (Please specify)

At risk for what type of out-of-home placement? (Psychiatric hospitalization, Foster care, Juvenile Court Placement, Other) (Please specify)

If yes explain

Legal Guardian(s) Relationship:

Biological Mother

Biological Father

Address

Other mental health services in the household

Other mental health services in the household?Which family members are they working with?

Which family members are they working with

Others living in household Last Name

Describe detailed information regarding psychiatric symptomsbehavior problemssignificant psychosocial stressors that may interfere with childfamily function in the home

Previous and Current Mental Health Treatment of member ICM/RC or Blended CaseBHRS (Wraparound) Family Based Psychiatric Hospitalization RTF or CRR

Frequency

Name

DOB

MA

Any medical concerns: School/Grade/IEP?

Has the child had a physical examination in the past 12 months?

Has the child had psychiatric/psychological evaluation in the past 6 months?

FAMILY STRENGTHS (include individual strengths, family strengths, natural supports and community linkages)

Is the child returning home from an out-of-home placement and FBMHS is needed as a step-down? (Yes/No) If yes, please describe.