Dayton PCS SUMMER Camp Client Referral (I)

Primary Care Solution Summer Camp Client Referral
Date of Referral*

MonthDayYear
Date
Referral Agency / Organization
Child Information
Client Name
Date of Birth

MonthDayYear
Date
Social Security Number*
Home Address
Phone Number
Format: (000) 000-0000.
CHILD-SPECIFIC INFORMATION
Who does the child live with?
Name of School
Grade Level
Shirt Size
YesNo
If yes please list their diagnosis
YesNo
If yes please list their diagnosis
PARENT/GUARDIAN INFORMATION
Full Name*
Email Address*
example@example.com
Home Address*
Phone Number
Format: (000) 000-0000.
Cell Number*
Emergency Contact Name
Emergency Contact Name: Phone Number
Format: (000) 000-0000.
Relation
Emergency Contact Name
Emergency Contact Name: Phone Number
Format: (000) 000-0000.
Relation
REASON(S) FOR REFERRAL - CONCERN(S) RELATED TO: (Check all that apply)
Does Not Complete AssignmentsFrequent TardinessShort Attention SpanLeaves Class/School/WorkLacks Motivation/Uninterested in School/WorkPoor AttendanceMoves ConstantlyEasily DistractedDestruction of PropertyPoor Peer RelationshipsCompletion of AssignmentsFrequent Trips to School NurseAcademics: Low Scores/Failing GradesWork Habits/OrganizationPoor Employee PerformanceDrop-out Risk (H.S)NOT APPLICABLE
DefiantNot Using ToiletStealsDramatic Changes in BehaviorAlways TiredWithdrawnSelf-image / ConfidenceAnxious/NervousSwearingLyingDisrespectfulImpulsiveSelf-harmInattentiveCries EasilyNon-touchable / Pulls AwayChews Paper/Clothes/HairStealingSexual Acting OutLack of Social SkillsOutburstsMakes Odd SoundsSubstance AbuseNOT APPLICABLE
Feels WorthlessMood SwingsFeels UnlovedGriefWorriesSadnessFamily ConcernsNOT APPLICABLE
Teased / DislikedSuspected Gang MemberIsolated / WithdrawnNegative LeaderNOT APPLICABLE
Victim of ViolenceTraumatic ExperienceWitness to ViolenceDeath/Injury of family member or friendSchool / Workplace Violence / ShootingNOT APPLICABLE
ADHDAutism (ASD)Anxiety DisorderBipolar DisorderOppositional Defiant Disorder (ODD)Specific Learning Disabilities (SLD)Conduct DisorderObsessive-Compulsive Disorder (OCD)Learning DisabilitiesPost Traumatic Stress Disorder (PTSD)Sensory Processing Disorder (SPD)NOT APPLICABLEOther
Personal HygieneHealth Care Needs: Dental/Vision/Physician CarePhysically Strugging / Unable to Complete TasksWeightNOT APPLICABLE
Other Reason /Concern (Please Explain):
Please add your initials next to each section and check the boxes where needed to show your consent.
MEDIA CONSENT
I give permission for PCS Cincy Summer Camp, its partners, and media companies to use my child's photo, video, voice, and creative work (like art or writing) for promotional use, including websites and printed materials.
YesNo
Parent Guardian Initials*
COUNSELING SERVICES
I allow my child to participate in one-on-one counseling services provided by PCS Cincy Therapists. **Parent/Guardian Initials:
YesNo
Parent Guardian Initials*
MEDICAL INFORMATION
Does your child have any medical conditions (allergies, medications, physical impairments, recent surgeries, etc?
YesNoN/A
If yes please explain
Parent Guardian Initials*
BEHAVIORAL HEALTH SUPPORT
Is your child currently experiencing behavioral or emotional challenges, or receiving mental health services?
YesNoN/A
If yes please describe diagnosis triggers strategies that help etc
Parent Guardian Initials*
FOOD ALLERGIES OR DIETARY NEEDS
Does your child have food allergies or dietary restrictions?
YesNoN/A
If yes please list them and complete the additional allergy form
Parent Guardian Initials*
I agree to follow PCS Cincy's Discipline and Anti-Bullying Policy.*
I understand my child's participation in the program is voluntary.*
I will support daily attendance and notify staff of any absences.*
I give permission for my child to join all camp activities and field trips.*
I understand PCS and its staff/partners are not responsible for accidents or injuries unless due to gross negligence.*
I give consent for emergency medical or dental care if I cannot be reached, including hospital transport if needed.*
I understand my child may be removed from camp due to repeated unsafe behavior.*
My child will only be released to adults listed on this form.*
If selected for transportation, I understand my child will ride the designated bus/van daily and must arrive at the stop 10 minutes early. I will make sure my child knows what to do if I am not present at drop-off.*
Signature of ParentGuardian

Clear
Print Name of Parent Guardian
Todays Date

MonthDayYear
Date
Please return this form to Primary Care Solutions via email at PCS513SummerCamp@gmail.com We will contact you if we have any questions or need additional information. Call us at 513-440-3940 if you have any questions. Thank you for your referral!
Should be Empty:

CHILD-SPECIFIC INFORMATION

PARENT/GUARDIAN INFORMATION

MEDIA CONSENT

COUNSELING SERVICES

MEDICAL INFORMATION

BEHAVIORAL HEALTH SUPPORT

FOOD ALLERGIES OR DIETARY NEEDS