Children & Youth Clinical Referral

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Children & Youth Clinical Referral

  • Demographic Information

  • If legal guardian, a court order must be attached.
  • School / Education

  • Living Situation

  • Behavioral Health Diagnosis

  • Medical Diagnoses Impacting Behavioral Health Diagnosis

  • Psychosocial/ Environmental Elements Impacting Diagnosis

  • Current Medication

  • Referral Source

  • I understand that I am applying for Care Coordination in Choose an item.. This service has been explained to me and I understand that if approved I will participate in development of a Plan of Care with a team of people working with my family. I authorize the release of information to the Care Coordination Organization in Choose an item. so they can conduct a full screening and initiate an eligibility determination by the Administrative Service Organization (ASO) to determine my eligibility for Care Coordination services. I understand that I may revoke my permission at any time by written or verbal request.