CLTS Referral Form

1
Child's Full Name* This field is required.
First Name
Middle Name
Last Name
2
Date of Birth:* This field is required.
Date
Year
Month
Day
3
Gender:
4
Diagnosis: * This field is required.
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Child's Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Primary Phone Number:* This field is required.
Please enter a valid phone number.
7
County of Residence:
8
Parent/Guardian Full Name(s):* This field is required.
First Name
Last Name
9
Relationship to Child:* This field is required.
10
Primary Phone Number(s):* This field is required.
Please enter a valid phone number.
11
Primary Email Address(es):* This field is required.
example@example.com
12
Name:* This field is required.
First Name
Last Name
13
Relationship to Child:* This field is required.
14
Phone Number:* This field is required.
Please enter a valid phone number.
15
How did you hear about us? * This field is required.
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16
Is your child currently a participant in the Children's Long-Term Support (CLTS) program or have they ever been?* This field is required.
YESNO
17
If yes, please provide the name of your CLTS Service Coordinator:* This field is required.
18
Case manager/facilitator phone/email
Please enter a valid phone number.
19
Do you believe your child may be eligible for CLTS or other waiver programs?* This field is required.
Yes
No
Unsure
20
Have you completed a Functional Screen for your child?* This field is required.
YESNO
21
Service Request(s)
Respite
Mentoring
Health and Wellness
Daily Living Skills Training
Grief and Bereavement Counseling
Counseling and Therapeutic Services
22
Availability for treatment:
Weekly
Bi-weekly
Monthly
Telehealth
23
In your own words, what are the primary reasons you are seeking counseling for your child at this time?* This field is required.
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24
What are some of your child's interests, hobbies, and favorite activities?* This field is required.
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25
What are some of your child's greatest strengths?* This field is required.
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26
What are your family's greatest strengths or resources?* This field is required.
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27
Please describe any significant developmental milestones (e.g., speech, motor skills) and any concerns you've had:* This field is required.
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28
Please list any current medical diagnoses, chronic conditions, or physical disabilities:* This field is required.
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29
Please list any medications your child is currently taking (include dosage and purpose):* This field is required.
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30
Has your child ever been hospitalized for a mental or physical health concern? If so, please explain:* This field is required.
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31
Has there ever been a time when your child has been at risk of harming themselves or others?* This field is required.
YESNO
32
If yes, please explain:* This field is required.
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33
What school does your child attend and what grade are they in?* This field is required.
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34
Do they have an Individualized Education Program (IEP) or a 504 plan?* This field is required.
YESNO
35
How is your child's academic performance and social experience at school?* This field is required.
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36
Please describe your child's friendships and social interactions:* This field is required.
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37
Who does your child live with?* This field is required.
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38
Please describe your home environment and family dynamics:* This field is required.
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39
Appointment* This field is required.
40
Signature* This field is required.
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