Pathways To Success Referral Form
For Pathways to Success care coordinators. Dabney Behavioral Health will contact you and the family within 24-48 hours. Questions? Call (773) 651-6809. Your information is kept confidential and protected under HIPAA. Privacy Notice: https://www.dbhhc.org/privacy/
1. About you (the referring care coordinator)
Referring agency
*
Please Select
Ada S. McKinley
Arukah Institute
Association for Individual Development
Centerstone
Dupage County Health Department
Family Service Association of Greater Elgin
Kenneth Young Center
Lake County Health Department
Lutheran Social Services of Illinois
Metropolitan Family Services
Pillars Community Health
Rosecrance - Will County
Rosecrance - Kankakee
Sinnissippi Centers
Transitions of Western Illinois
UCAN
The Center for Youth & Family Solutions
Other (Not listed here)
Agency name (only if you chose Other)
Your name
*
First Name
Last Name
Your phone number
*
Format: (000) 000-0000.
Your email
*
2. Youth and family
Youth legal name
*
First Name
Middle Initial
Last Name
Youth date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/guardian name
*
First Name
Last Name
Parent/guardian phone number
*
Format: (000) 000-0000.
Parent/guardian email (if they have one)
Youth home address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County
Has the youth's parent/guardian agreed to this referral and to being contacted by Dabney Behavioral Health?
*
Yes
No, not yet (please explain under Additional Information)
Does the youth or family need Spanish-speaking staff or an interpreter?
No, client & family speak English.
No, client & family don't speak fluent English, but are okay with English-speakers.
Yes, client only speaks Spanish.
Yes, caregiver only speaks Spanish.
Yes, client and/or caregiver needs translation services for another language.
Other
Other language needs (which language?)
Best days and times to reach the family or schedule
3. Pathways eligibility and insurance
Pathways eligibility start date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Start Date
Pathways eligibility end date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
End Date
Pathways services requested (check all that apply)
*
Intensive Home Based
Therapeutic Mentoring
Family Peer Support
Respite
Primary insurance
*
Aetna Better Health
Blue Cross Community Health
County Care
IL Medicaid
Meridian
Molina Health
Youthcare
Other
Youth Medicaid / Member ID (9 digits)
*
Numbers only, 9 digits
4. Clinical information and documents
Presenting problem (a few sentences)
*
Diagnosis, if known
Upload if available: IATP, IM+CANS, Crisis/Safety Plan (CPSP), SNCD form
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Other documents, such as a Release of Information (ROI)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Anything else we should know?
Submit
Primary insurance
Aetna Better Health
Blue Cross Community Health
County Care
IL Medicaid
Meridian
Molina Health
Youthcare
Other
Should be Empty: