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Referring Agency

Name of Agency

Name of Referrer

Phone

Child/Adolescent

Child/Adolescent Name

Address

City

State

Zip

Age

Gender

Date of Birth

Social Security Number

Parent/Guardian Contact Information

Parent/Guardian Name

Address

City

State

Zip

Phone

Custody

Is this child in custody of DSS?

Yes

Have parental rights been terminated

Yes

Child/Adolescent's Current Placement

If other, please explain

Reimbursement

Reimbursement Type

IEP

Yes

Date of Current IEP

Grade

School

FSIQ

Document Upload

PLEASE UPLOAD as many of the following documents as possible:

Most recent psychological evaluation and psychiatric evaluation.
Discharge summaries from previous treatment providers within last year.
Social history – Pre/Post Dispositional Report - Foster Care Service Plans.
Documents with Information describing behavior within past 2 months (treatment plans, nursing/progress notes, progress summary reports) indicating medical necessity for secure RTC treatment.

Brief description of files being uploaded

Document

Combined total of all files may not exceed 7MB.

Referral Application