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.
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.
