Crs Referral Form

CRS REFERRAL FORM

Youth’s Name:______Sex:____ Age:______DOB:______

Youth LGBTQ? qYes qNo Youth Transgendered? qYes qNo

1) Is the child Hispanic/Latino (Yes, no, unknown, refused) a) If yes, what ethnic group? (Central American, Cuban, Dominican, Mexican, Puerto Rican, South American, Other (please specify)) b) If Other; Please specify______

2) What is the child’s race? (If multiracial, circle all that apply) (Black/African American, Asian, Native American or other Pacific Islander, Alaskan Native, White, American Indian, Refused)

Type of Primary Insurance:______Subscriber #:______

Name of Policy Holder (If Private):______DOB:______

Type of Secondary Insurance:______Subscriber #:______

Name of Policy Holder (If Private):______DOB:______

Does Parent/Caregiver Have Custody q Yes qNo qShared (DCF/Parent) qShared (Between Parents)

Name of Parent/Caregiver 1:______Relationship to youth:______

Home Phone:______Cell Phone:______

E-Mail:______Caregiver aware of referral? qYes qNo

Name of Parent/Caregiver 2:______Relationship to youth:______

Home Phone:______Cell Phone:______

E-Mail:______Caregiver aware of referral? qYes qNo

Youth’s Physical Address:______

Street Apartment # City State Zip code

DCF Involvement: qYes qNo qCustody Social Worker Name:______E-Mail:______Phone #:______

Preferred Language of Youth:______Preferred Language of Parent:______

Person/Agency Making Referral:______Relationship to Youth:______E-Mail______Phone #:______

Is the family involved with the military: qYes qNo If yes, please describe:______

Is the family involved with the court: qYes qNo If yes, please describe:______

Name of School:______Grade______IEP/504: qYes qNo

Developmental Delay/Intellectual Disability:______

Primary Care Physician:______Phone: ______

Other Providers Involved:______Phone:______

Does family have access to transportation for treatment? qYes qNo

Other possible barriers to treatment______

***PLEASE COMPLETE THE TRAUMA SCREEN ON THE NEXT PAGE**

History of Trauma and Behaviors Related to the Trauma: ______

Trauma Screen: History (Check all that apply)

qSexual Abuse qEmotional/Psychological Abuse qDomestic Violence qCommunity Violence

qPhysical Abuse qSevere Accident or Illness q Parental Substance Abuse qTraumatic Grief

qNeglect qWar/Terrorism/Immigration qNatural Disaster qParent Mental Illness

qFrequent Moves qParent history of trauma qKidnapping qSchool Violence/Bullying

qHomelessness qParent Incarcerated qParent Deployed

q Systems-Induced Trauma (ie. Removal/multiple placements qVictim of Commercial Sexual Exploitation (CSEC)

qSeparation from parent due to death, divorce, abandonment or other reason.

qOther (please explain)______

Current Reactions/Behaviors/Functioning Related to the Trauma (Check all that apply)

qOppositional Behaviors qDepression qSelf-Harm qDissociation qImpulsivity

qAttention/concentration qConduct Problems qSleep Difficulties qAnger Problems qRegression

qSuicidal Ideations qHomicidal Ideations qAudio Hallucinations qVisual Hallucinations qAnxiety

qSexualized Behaviors qAnimal Cruelty qAttachment/relationship

qSomatization/Physical qProblems with Difficulties

Complaints Emotional Regulation q Other:______

Current Posttraumatic Stress Reactions Related to the Trauma (Check all that apply)

q Re-experiencing (nightmares, flashbacks or intrusive thoughts)

q Avoidance (not want to talk about the trauma, avoiding trauma reminders)

q Numbing (lack of emotion, social withdrawal)

q Hyperarousal (exaggerated startle response(s), hyper-vigilance, being “on edge”)