Level 3 Therapeutic Group Home Referral Form
Please complete this form to refer a client to a Level 3 Therapeutic Group Home, including all relevant clinical and placement details.
Referral Information
Date of Referral
*
-
Month
-
Day
Year
Date
Referral Source/Agency
*
Case Manager Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Client Information
Client Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Male
Female
Non-binary
Prefer not to say
Other
Medicaid ID #
Current Placement
Legal Guardian Name
Guardian Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Clinical / Behavioral Information
Primary diagnosis
*
Secondary diagnosis
Current behaviors of concern
*
History of aggression, elopement, or self-harm
*
Current medications
Placement Information
Reason for Referral to Level 3 Group Home
*
Previous Placements
School Information
Current Therapy Services
Probation / Court Involvement (if applicable)
Required Documents Checklist
Psychological evaluation
Attached
Pending
Not available
Person-centered plan (PCP)
Attached
Pending
Not available
Medication list
Attached
Pending
Not available
Incident reports
Attached
Pending
Not available
Insurance / Medicaid information
Attached
Pending
Not available
Birth certificate / Social Security card
Attached
Pending
Not available
Educational records / IEP
Attached
Pending
Not available
Other:
Other
Approval / Signatures
Referring Person Signature
*
Date
*
-
Month
-
Day
Year
Date
Agency Representative Signature
*
Date
*
-
Month
-
Day
Year
Date
Upload Files
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit Referral
Submit Referral
Should be Empty: