AYS ARCS Combined Referral, Intake & Service Planning

Atlanta Youth Services Autism Respite Care Services Intake and Referral

Complete the referral, intake, and service planning details, then upload supporting documents and sign to submit.
Referral
Referrer name

First NameLast Name
Relationship to child

Other
Referrer email
example@example.com
Referrer phone
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?
Child/youth full legal name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Eligibility category
Autism diagnosis status
Reason for referral
Intake
Is the primary caregiver the same person as the referrer?
Primary caregiver name

First NameLast Name
Primary caregiver email
example@example.com
Primary caregiver phone
Please enter a valid phone number.Format: (000) 000-0000.
Service address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Information
Case manager name

First NameLast Name
Case manager email
example@example.com
Case manager phone
Please enter a valid phone number.Format: (000) 000-0000.
Case manager county
Emergency contact
Emergency contact name

First NameLast Name
Emergency contact phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency contact relationship
Add your requested service dates and times below:
Service Planning
ARCS services are available for a minimum of 4 hours per service day, up to 14 service days per month. Overnight services and 24-hour care are available. Services are approved month to month. Please list all requested dates and times for the month in which services are needed.
Schedule Flexibility
Medical, Allergy & Care Instructions
Allergies
Does the child have any known allergies?
Please list all known allergies and describe the child's reaction, if known.
Include allergies such as food, medication, environmental, insect, or other allergies.
Does the child have an emergency allergy response plan or require an emergency medication (such as an EpiPen)?
Please provide the emergency allergy instructions the provider should follow.
Medications
Does the child currently take any medications that may need to be taken during requested ARCS service hours?
Medication Name
What days and times is this medication taken?
Will the medication need to be administered or assisted with by the ARCS provider during service hours?
Please provide medication instructions and any information the provider needs to know.
Add another medication?
Medication 2 — Medication Name
Medication 2 — What days and times is this medication taken?
Medication 2 — Will the medication need to be administered or assisted with by the ARCS provider during service hours?
Medication 2 — Please provide medication instructions and any information the provider needs to know.
Are there any further medications to add?
Further medications — names, days and times, and provider assistance needs
List every further medication separately with its name, days and times taken, and whether provider assistance is needed (Yes, No, or Unsure).
Will any further medication need provider administration or assistance?
Further medications — provider instructions
Identify each medication requiring assistance or where assistance is unsure and give the instructions the provider needs.
Medical Concerns
Does the child have any medical conditions, health concerns, or medical needs that the provider should be aware of?
Please describe the child's medical condition(s), health concern(s), or medical needs and explain what the provider should know while caring for the child.
Are there specific warning signs, precautions, restrictions, or emergency instructions the provider should follow related to this medical concern?
Individual Care Plan / Provider Instructions
Does the child have a specific care plan, safety plan, behavioral support plan, routine, or other instructions that the ARCS provider needs to follow while providing services?
Please describe the care plan or specific instructions the provider must follow while working with the child.
Include any relevant information regarding routines, communication needs, behavioral supports, supervision requirements, mobility/personal care needs, feeding instructions, sensory needs, safety precautions, triggers, de-escalation strategies, or other individualized instructions.
Do you have a care plan or supporting document that should be provided to Atlanta Youth Services?
Care plan or supporting document

Cancelof
Document Upload
Please upload ASD evaluation

Cancelof
Referrer Signature
Referrer signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Atlanta Youth Services Autism Respite Care Services Intake and Referral

Referral

Intake

Service Planning

Medical, Allergy & Care Instructions

Allergies

Medications

Medical Concerns

Individual Care Plan / Provider Instructions

Document Upload

Referrer Signature