Referral Form
Please check which school:
□ Lariat School □ Therapeutic Educational Center
Instructions for completing form:
o Three sections to complete: Referring School, Parent/Guardian, and Compass Behavioral Health
o Please be sure to complete the return address portion at the top of each section.
o The Referring School/Agency will distribute collect the completed sections and submit the entire referral to C. Brian Hastings, LMFT at 11200 Lariat Way, Dodge City, KS 67801. Please feel free to call (620)338-4955 if any questions or concerns.
o It is the responsibility of the Parent/Guardian to call (620)227-8566 and schedule an intake at Compass Behavioral Health and advise clerical that they are pursuing TEC placement. If assistance is needed, please contact Vicki Broz or Richard Falcon at that same number.
o Lariat School referrals must be accompanied by a 504 Plan
Please complete and returned to: (address of school/agency that sent form)
Agency/School Name______
Street Address______City/State/Zip______
Phone______Fax______
Contact Person______
______
Student Name ______Social Security Number
Gender______Date of Birth __ Age __ Grade______IEP _____YES _____NO
If yes, percent/time in SpED ______Area of Exceptionality ______
Parent/Guardian ______Relationship to child
Address ______City/State/Zip
Home Phone Work Phone Cell Phone
Referred by: School ___ Mental Health ___ SpEd ___ Other ______
Person Referring Title ______
Date of Referral ______
Has the student ever had an appointment at Compass Behavioral Health? _____YES _____NO
Date of most recent appointment ______
1
Referring School Section
Principal ______
SpEd Instructor ______School Psychologist ______
Person responsible for referring student materials:
Academic issues (attach supporting evidence including IEP):
______
______
Intervention strategies (attach supporting evidence):
______
School behavioral issues:
______
Intervention strategies to manage school behavioral issues:
______
Social skills issues:
______
Submit a copy of the student’s behavioral plan with evidence of success and failure.
Previous or current risk of injury to self or others:
______
Other information to be considered (general education interventions, student improvement reports, etc.):
______
Lariat School / Therapeutic Educational Center (TEC) begins the transition process back to the referring school the day the student is admitted to the program. Our goal for the student is to assist him/her in getting his/her behavior to a manageable level. The referring school will specify the specific concerns leading to the referral as well as the behavior expectations for the student to return. Utilizing this information, our staff will prioritize the behaviors to be targeted for treatment and set transition goals. It is understood that our staff will outline the transition timeline when the process begins. It is the referring school’s responsibility to provide transportation after the first week of the transition timeline.
Please list in order of importance the specific concerns and behaviors that lead to the referral.
1.
2.
3.
4.
Please list the behavioral expectations for the student to achieve.
1.
2.
3.
4.
Parent/Guardian Section
It is the responsibility of the Parent/Guardian to call (620)227-8566 and schedule an intake at Compass Behavioral Health and advise clerical that they are pursuing placement. You may ask for Vicki Broz or Richard Falcon if you need assistance in scheduling.
(Address of school/agency that sent form) School/Agency Name ______
Street Address
City/State/Zip
Phone
Contact Person ______
Student Name ______
Parent/Guardian ______Parent___ _ Foster Parents__ Other
Address ______City/State/Zip______
Home Phone ______Cell Phone ______
Foster Care Contact Person Title ______
Address ______City/State/Zip
Phone Fax Cell Phone
Behavioral issues at home: ______
______
______
Behavioral issues at school: ______
______
______
Medical history: ______
______
______
Family mental health history: ______
______
______
Developmental history, including pregnancy: ______
______
______
Previous or current risk of injury to self or others: ______
______
______
______
Previous or current home environment issues (parental: substance abuse; employment; etc.: ______
______
______
Previous or current court legal issues:______
______
Previous or current substance abuse:______
______
______
______
Other pertinent information: ______
______
Mental Health Provider Section
Student Name Agency ______
Phone Therapist ______
Case Manager ______
DSM 5 Diagnosis:
Previous or current mental health treatment (attach copy of treatment plan if available):
Previous or current hospitalization(s) for mental health issues (attach copy of discharge if available):
Medications for mental health issues:
History of abuse (physical, sexual, emotional):______
______
History of neglect or inadequate supervision:______
______
Previous or current risk for injury to self or others:
Social skills issues:
Family mental health history:
Previous or current home environment issues (parental: substance abuse; employment; etc.):
Previous or current court or legal issues:
Previous or current substance abuse issues:
Other pertinent information:
Revised 11/22/16