Eliot Community Human Services |
p. 1 of 2 |
CBHI - CSA |
Rev 10/22/10 |
REFERRAL |
CSA FORM - 1 |
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YOUTH’S NAME: _________________ DOB: ____/____/____ AGE: ______DATE OF REFERRAL: ____/____/____
REFERRER INFORMATION:
PRINT name: ________________________________ Phone Number: (____)_____‐__________ E‐mail: ______________________
PRINT agency: _______________________________ Role: ___________________
Please attach most recent: Assessment ; Service Plan; Safety Plan; Ed Plan; Other: ____________________________
YOUTH INFORMATION:
Gender F M Social Security # ____ ‐ ____ ‐ ____ Race/Ethnicity: _____________ Primary Language __________________
Insurance (check one): Network Health; Beacon Strategies (NHP, Fallon, BMC); MBHP Member ID # ____________________
Youth currently resides: Home; Foster Home Shelter:_________ Treatment Facility:___________ Other:______________
Date of admission to current facility (as applicable): ____/____/____Date of expected discharge ____/____/____
Address of current residence: _______________________________Apt.____ City _____________________ Zip Code _____________
Residence Contact name: ________________________Contact Number: (___) ____‐_______ Alternative Number: (___) ____‐_____
Is youth enrolled in school? Y N. If yes, name of school: __________________________ Grade: _______ IEP Yes No
School address: _________________________ City _____________________ Zip Code ___________ Number: (____) ____‐_____
PARENT/GUARDIAN INFORMATION:
Guardian Name:______________________________________________ |
Primary Language: ________________________________ |
Guardian Name:______________________________________________ |
Primary Language: ________________________________ |
Address (if different then youth’s): ___________________Apt.____ City __________ Zip Code _______Contact Number: (___) ____‐______
Description of family make up/who lives in home: ___________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Are there any special languages, cultural, medical needs for this family? Y N.
If yes, please explain:___________________________________________________________________________________________
Strengths and special interests of the youth and family:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
RELEVANT INFORMATION:
Presenting Problem and/or specific goals to be addressed:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Brief summary of prior assessments completed:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Eliot Community Human Services |
p. 2 of 2 |
CBHI - CSA |
Rev 10/22/10 |
REFERRAL |
CSA FORM - 1 |
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RELEVANT INFORMATION (cont’d):
Please check if the youth has had other out of home placement(s) Y N
History of psychiatric hospitalization(s) Y N Most current psychiatric hospitalization date: ____/____/____
Diagnosable mental, behavioral or emotional disorder Y N
Most current diagnosis: (include DSM‐IV‐TR Code)
AXIS I: ____________________________________ |
AXIS II: ______________________________________ |
AXIS III: ___________________________________ |
AXIS IV: ______________________________________ |
AXIS V: ___________________________________ |
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Brief family history/dynamics related to current problem:
If you have attached updated assessment, service plan or risk plan, write “see attached” below.
Include any history of mental illness, substance abuse, domestic violence, sexual or physical abuse, cultural factors, and medical history.
POTENTIAL TEAM MEMBERS ‐ CURRENT SUPPORT SYSTEM/AGENCY INVOLVEMENT:
Provider |
Contact Person |
Agency |
Phone Number |
PCP |
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Therapist |
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DCF |
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DMH |
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Psychiatrist |
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Natural Support(s) |
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Other |
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MEDICATIONS: Compliant Y N
Name of Medication(s) |
Dose |
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The family understands the Intensive Care Coordination and Family Support role and agrees to work with the CSA voluntarily Y N
Family understands that an Eliot staff member will contact them and the above support system and/or agency involvement to learn more about the youth to determine whether she or he meets the eligibility criteria, will contact the referrer for more information and will contact MassHealth to confirm her or his MassHealth eligibility. Y N
Parent/ Guardian signature ______________________________ |
Signature Youth over 18: _________________________________ |
