SCLHSA/CART Referral Form

SCLHSA/CART Referral Form

NSU-Family Service Center

Initial Subsequent

Date of Referral: / Child’s Name (first middle last):
Gender: Race/Ethnicity: / / D.O.B.: Age:
Mailing Address: / Phone #: Alt. Phone #:
Physical Address: / Social Security Number:
Biological Parents’ Name: / Guardian’s Name:
Grade Level: / Name of School:

Reason Child Not in School: Too Young Expelled Pregnant Dropped Out Suspended

Family Type: Biological Adoptive Foster Relative Legal Guardian Family Size:

Referral Classification: Crisis Non Crisis Identify Dates of Any Court Hearings:

Referral Source:  CART Mental Health Clinic:

Check the Appropriate Referral Type:  Voluntary Court Ordered

Reason for Referral: (Check all that apply)

 Prevention of Long Term Mental Illness / Juvenile Diversion
 Crisis Intervention / Parental Support
Child Management Issues (Behavior Problems/Unruly) / Other:
Child Educational Issues

Special Circumstances: Mental Illness Criminal Record Violent Potential

(Check all that apply) Children in Foster Care Substance Use/Abuse Disability

Behaviors/Disabilities:

Indicate All Behavioral Health Services Currently Receiving:

Services Requested: (Check all that apply)

Case Management / Training / Family Support / Financial Counseling
Psychotherapy / Knapsack / Parenting / Housing Assistance
Psychological Evaluation / PREP / Transportation / Info/Referral/Advocacy
Skill-Building / Support Group / Resource Library / Telephone Support
Education / Tutoring / Mentoring / Legal Services / Le Cirque-Living Skills
Referring Agent: / Agency Name: / Phone #:
Program Area: / Supervisor: / Phone #:

As applicable per your program, please supply all appropriate supporting documentation such as psychosocial histories, assessments, treatment plans, etc.

SCLHSA/CART Referral Form

ADULT INFORMATION

Adult Family Members Residing in the Household (18 years old and older)

Name / D.O.B. / Sex / Race/
Ethnicity / Marital Status / Relationship to
Child Referred
FM / / / MSSEDCO
FM / / / MSSEDCO
FM / / / MSSEDCO
FM / / / MSSEDCO

Adults in the Household Referred for Service

Adult’s Name: / D.O.B.: Age: Gender:
Address: / Phone #:
Social Security Number: / Emergency Contact Name & Phone #:
Race/Ethnicity: 010204051199 / Educational Level:
Employer: / Employer’s Address:
Employer’s Phone: / Income: under $5,000 $5,000 to 12,000
$12,001 to $25,000 $25,001 to 50,000
$50,001 to 75,000 Over $75,000

Special Circumstances: Mental Illness Criminal Record Violent Potential

(Check all that apply) Children in Foster Care Substance Use/Abuse Disability

Services Requested: (Check all that apply) No Services Requested

Indicate All Behavioral Health Services Currently Receiving:

Notes: