Crisis House Referral Form

Crisis House Referral Form
PRELIMINARY ADMISSION CRITERIA TO SUMMIT HOUSE

If any of the below criteria are met, youth would not be appropriate for Tanager's Summit House
1. Youth is not between the ages of 8 and 17
2. Legal guardian is not available to consent to referral, and possible placement
3. Youth has complex medical issues such as uncontrolled diabetes/seizure disorder, poorly controlled feeding or eating disorder
4. Youth is in need of 1:1 support related to level of functioning, psychiatric severity, or medical condition
5. Youth has exhibited active violence, and/or crises that involve firearms or weapons
6. Youth's presenting problem is related to substance abuse, or exhibits medial instability related to intoxication / withdrawal
If questions Call Summit Referral #319-451-7889
REFERRAL INFORMATION
Name of Referrer [person completing form]*

First NameLast Name
Relationship to Youth / Agency
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Reason for Referral: *
Where is the youth currently residing?*
If Summit House were not available, where would the youth have gone?*
Date and Time of Referral

MonthDayYear
Date
Hour MinutesAM/PM Option
YOUTH INFORMATION
Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Physical Descriptors:

HeightWeightHair Color
Youth's Grade in School:
School Attending:
Race

WhiteAfrican AmericanAsianBi-RacialHIspanicNative AmericanPacific IslanderAfricanOther
INSURANCE INFORMATION
Medicaid / MCO

IMEIowa Total Care / CenteneMolinaWellpoint
Medicaid ID#
Medicaid ID will be 7 numbers and 1 letter
Commercial Insurance Company
Insurance ID:
Subscriber Name:
Relationship to Subscriber:

ChildSpouseSelfOther
LEGAL GUARDIAN CONTACT INFORMATION
Is same as referrer
Name:

First NameLast Name
Relationship to Youth
Address is same as youth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
- Date/Time of Scheduled Assessment:
  
  MonthDayYear
  Date
  Hour MinutesAM/PM Option
- Date/Time of Admission:
  
  MonthDayYear
  Date
  Hour MinutesAM/PM Option
- LMHP Review needed? [if so, enter their email address for document to be forwarded to them]
  example@example.com
- Referral Source
  
  Internal Tanager ProviderExternal Therapist / ProviderFoundation 2 / Mobile Crisis ProviderGuardianHospitalSchoolOther
- Should be Empty:

Crisis House Referral Form

REFERRAL INFORMATION

YOUTH INFORMATION

INSURANCE INFORMATION

LEGAL GUARDIAN CONTACT INFORMATION