If it is the intention of the referral that the child be considered for OUT-of-HOME SERVICES or for WAIVER SERVICES, the following documents must be included: Psychiatric Evaluation (current to within the last 6 months) - Please include mental status, history of psychiatric care and treatment, DSM IV, emotional strengths and weaknesses, including frustration tolerance, prognosis, and a brief medication history. Psychological Evaluation (current to within the last 12 months) - Please include intellectual functioning, prognosis, social-affective functioning, any sensory, behavioral, and language skills and deficits, prior history of psychological problems, gross and fine motor coordination and self-help skills. Psychosocial History (current to within the last 12 months) - Please include family and community relationships, strengths and weaknesses in the familial constellation, emotional and health factors of the family, religious and ethnic affiliation. Physical/Medical Evaluation (current to within the last 12 months) - Please include a developmental history which contains an assessment of pre and post natal periods, developmental milestones, problems and experiences which have interfered or may interfere with future development, and peer relationships and/or activities. IEP (current to within the last 12 months) - Please include an assessment of current school status and vocational assets and liabilities; which include where available and appropriate, intellectual and achievement tests. Describe what has been helpful in the classroom to handle disruptive behaviors, if any. Describe what has been helpful in the areas of use of free time, motivation, and affective incentives and re-enforcers. Referral Summary (needed for RTF only) Please attach a brief summary of the most salient features of the case, including examples and descriptions of behaviors that typify the child or youth’s response to current placement, include current information regarding performance of age-appropriate activities, interests, self-care skills, ability to relate to others, and certification by a mental health professional, who is familiar with the case so that the materials attached accurately reflect the child or youth’s current level of functioning. Please illustrate how all available lower levels of care have been accessed and utilized.	Follow instructions on the referral form for the level of care you are seeking. In order for your application to be considered complete, all documentation must be included. Download Form >>               OCMS 220 Herald Place, 3rd Floor Syracuse, NY 13202 Phone: 315.472.7363 Fax: 315.472.0084