Client Referral Form for Psychiatric Assessment

  • Client Referral Form for Psychiatric Consultation

  • Eligibility

    Psychiatric Consultation Services at the Washtenaw County Youth Center may only be requested for youth either currently being housed at the Youth Center on a court order or youth court ordered into the Washtenaw County Day Treatment Program.

    If the youth you are requesting services for does not meet this criteria, please contact Washtenaw County Community Mental Health Access at 734-544-3050 or 800-440-7548 at any time.

  • Please contact Washtenaw County Community Mental Health Access at 734-544-3050 or 800-440-7548 at any time.

  • Purpose of Consultation

    Outcomes of a youth receiving a psychiatric consultation at the Washtenaw County Youth Center may potentially include the following:

    • Psychiatric evaluation for new clients to determine possible needs
    • Medication recommendations
    • Prescribe/fill medications
    • Lab work/coordination with appropriate medical providers
    • Recommendations for referrals (e.g. therapy, psychiatric services, etc.)
    • Coordination with Youth Center educational program staff

  • Court Order, Consent, and Other Supporting Documents

  • Additionally, if any of the following supporting documents are available they may be submitted. This documentation is helpful in completing a comprehensive and accurrate assessment.

    • Medical History
    • Psychiatric History:
      • including discharge summary, if recent - psychiatric inpatient or partial hospitalizations.
      • Any medications the client is on,
      • Prior psychiatric evaluation(s)

    Any information provided via attachments does not need to be retyped in form (e.g. current medications, allergies, etc.)

    If you have any questions, please call Kevin Barnwell at 734-623-0401.

  • Youth Information

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  • Parent/Guardian Information

  • Referring Party Information

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  • Treatment History and Current Concerns

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  • Required and Supporting Documents

    Please include any applicable attachments below - multiple files may be attached.

  • Required Documents

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  • Supporting Documents

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  • For Office Use Only

  • Should be Empty: