Date:
Level 10/11 Level 12/13/14: Intensive Targeted Wraparound Services (ITWS)
Childs Name: / DOB: / Age: / Sex:
Social Security No.: / Medi-Cal Eligible? / Yes No
Medi-Cal Card (BIC) No. : / BIC Issue Date: /
Insurance Provider:
Ethnicity: / Language:
U.S. Citizen? / Yes No / If No, Prucol Eligible: / Yes No
For youth 17 ½ and older, will s/he be engaged in AB 12 foster care services? / Yes No
Referring Department:
Worker’s Name:
Cell Phone #: / Office #: / Fax #:
Email Address:
Parents (Mother) / Legal Guardian / Parents (Father) / Legal Guardian
Name: / Name:
Cell Phone #: / Home Phone #: / Cell Phone #: / Home Phone#:
Address: / Address:
Language: / Language:
Caregiver
Name:
Cell Phone#: / Home#:
Address:
Language:
Referral Criteria
Child has mental health needs / Yes / No
Family has multiple unmet needs / Yes / No
Placement is at risk due to behaviors, risk issues, trauma history and/or impairments to functioning. / Yes / No
Strengths of Clients
(1) 
(2) 
(3) 
Strengths of Family
(1) 
(2) 
(3) 
Abuse/Neglect / Mental Health / Physical /Sensory/Health Conditions
Physically abused Sexually abused / Prescribed Psychotropic Medication / Eating Disorders:
Emotionally abused Neglected / Previous psychiatric hospitalization / Chronic Medical Condition
Abandoned / History of suicidality/ideation/gestures / Type:
Severely medically neglected
Commercially Sexually Exploited Child (CSEC) / Vulnerability / Domestic Violence
Multiple placement / Witnessed
Lack of family involvement/supports / Experienced
Education / Delinquency / Sexual Adjustment/Functioning
Truancy / Offenses against persons / Sexual perpetrator
Expulsion or Suspension / Offenses against property / Inappropriate sexual behavior
Individual Education Plan / Drug/alcohol related offenses / (describe)
Use of weapons
Sets fires
Drug/Alcohol Use / Defiance / Gang Involvement / Associates
Drug use / Lacks bond with caregivers / Gang Member
Previous drug use / Gets into fights with peers / Which gang?
Alcohol use / Associates with gangs
Behaviors of Concern
Acts impulsively Verbal Aggression / Is depressed and/or withdrawn History of setting fires
Runs away from placements Physical Aggression / Exhibits frequent mood swings History of animal cruelty
Threatens verbally Damages property / Hallucinates/bizarre thoughts Self injurious behaviors

Does the child/youth currently have Systems of Care? Yes No If yes, who is the provider:

Are any of the child’s/youth’s siblings receiving Wraparound services? Yes No

Rational for wraparound including safety concerns:
DSM-IV: CURRENT DIAGNOSIS
Diagnosis made by (name and title):
Date of Diagnosis:
AXIS I:
AXIS II:
AXIS III:
AXIS IV:
AXIS V:
COMPLETE FOR ITWS & LEVEL 13/14 WRAPAROUND ONLY
As a result of a mental disorder, clients meets ONE OR MORE of the following two criteria:
Demonstrates substantial impairment in at least two of the following areas:
Self Care / Yes / No
School functioning / Yes / No
Family relationships / Yes / No
Community functioning / Yes / No
AND either of the following occurs:
Has been placed out-of-home or is expected to be placed out of home. / Yes / No
Disorder has been present for more than six months or is like to continue for more than one year without treatment. / Yes / No
Displays one of the following:
Psychotic features / Yes / No
Risk of suicide / Yes / No
Risk of violence / Yes / No
Referring Worker: / Date:
Referring Worker Supervisor: / Date:
RISC COMMITTEE APPROVAL SIGNATURES
DFCS: / Date:
JPD: / Date:
MH: / Date:
RISC COMMENTS:

Filing: 2nd Fastener, under [3] SCZ63-WRAP.doc

RISC returns this form to SW SCC RISC-WRAP Referral Form – 7/31/13