Henrico County MDT Initial Referral Form
Child’s First Name Middle Last
Case Manager Phone E-mail
Child’s Date of Birth SSN STI Student ID
Gender: Male Female Hispanic Status: Yes No
Race: AA/Black Asian American Indian/Alaskan Native
Hawaiian/Pacific White Other/Undetermined
Parent/Custodian Name Relationship to Child
Address (include city and zip code) Phone
Requested Service:
Child’s Strengths (related to psychological/behavioral/emotional function, home environment, school environment and legal custody status)
Child’s Needs (related to psychological/behavioral/emotional function, home environment, school environment and legal custody status)
Outcomes/Objectives (should be measurable and behaviorally specific, including target dates)
Current Placement:
Current FBA/BIP? (If yes bring plan/data) Yes No
Is child truant? Yes No
Special Education Disability:
Grade:
Is child a student with Autism? Yes No
Mental Health Diagnosis: Yes No Note: Yes includes diagnosis of ADD/ADHD
Mental Health Medications: Yes No Note: Yes includes medications for ADD/ADHD
Enrolled in Medicaid? Yes No
ATTACH MANDATORY FORMS: (MUST BE SUBMITTED TO RECEIVE AN MDT DATE)
CANS (if requesting funding; either attached or e-mailed to CSA staff)
RELEASE OF INFORMATION (all cases)
PARENT/CUSTODIAN MUST BE INVITED TO MDT BUT IS NOT REQUIRED TO ATTEND.
Referral Completed by Date
BEST PRACTICE TIP / Bring the child’s cumulative file as a resource for information.