SRTU Consultation Referral Packet Checklist
Upon receiving a SPEC or PCH IOS, or if the youth is pregnant and/or requires a mommy-and-me program only, the case/care manager should review the following checklist in order to assure that all necessary documents are included prior to mailing the referral package to SRTU for consultative review. A copy of this completed checklist should be included in the referral package that is mailed to SRTU. Incomplete packets will not be processed:
☐Cover letter with identifying information, which must include the following:
☐Youth’s name/CYBER ID#
☐Youth’s current location (if in detention or hospital, specify length of time at current location)
☐Date of OOH Referral Request/Telephonic Review/TJCR
☐Intensity of Service (SPEC, PCH, or Pregnancy/Mommy and Me)
☐Brief description why out-of-home treatment is necessary
☐Name, e-mail address, phone # of CMO Care Manager
☐Name, e-mail address, phone # of DCP&P worker (if applicable)
☐Name, e-mail address, phone # of CMO/DCP&P supervisor
☐Referent’s supervisor’s signature confirming review and approval of referral packet
☐ Copy of OOH Referral Request or Transitional Joint Care Review from CYBER (CMO only)
☐ Updated Clinical Documentation, which must include all of the following:
☐ Bio Psychosocial Evaluation or Psychological Evaluation w/in last 12 months
☐ Psychiatric Evaluation w/in last 6 months (this evaluation is required if youth
is prescribed psychotropic medication and/or had recent psychiatric
hospitalization). If the evaluation is older than six months, CM must provide the evaluation along
with an accompanying updated report from the treating clinician.
☐Specialty Evaluations, if applicable (evaluation must be within the last twelve months):
☐Fire Setting Evaluation (with documented risk level)
☐Psychosexual Evaluation (with documented risk level)
☐Other specialized evaluations that may impact decision making: ______
☐ Other Reports (as applicable):
☐Substance abuse assessment w/recommendations (within last 30 days)
☐Status of IDD Eligibility (if youth is intellectually/developmentally disabled)
☐Most recent IEP (if educationally classified)
☐Medical Reports (if youth has a medical condition)
☐ 26-80 form (if DCP&P involved)
☐Any other documents that were utilized for purposes of IOS determination: ______
☐Previous Out-of-Home Treatment Outcomes (if applicable):
☐ Discharge summaries from prior or current out-of-home treatment settings
☐ Rejection letters from referred out-of-home treatment programs
☐Court Involvement (as applicable):
☐ Status and copy of legal charges
☐ Probation reports
☐ Pre-sentencing report
☐ Court order for out-of-home treatment
☐ Court order of custody (if DCP&P involved)
Updated 3/12/14