THIS FORM IS FOR FAX REFERRALS ONLY. TO PROTECT PRIVACY PLEASE DO NOT EMAIL THIS FORM.

WESTCOAST CHILDREN’S CLINIC FAX REFERRAL FORM

Fax form to 510-269-9031: ATTN INTAKE

Date: / Referral Source:
Agency:
What is your role in the child’s/youth life? / Intake Clinician:
Client Name:
Gender: DOB: / Place of Birth
County
State
Country / SSN:
CIN #:
CWS/CMS Client ID:
[Alameda SSA only; see client ID tab in CWS/CMS]
Address (if homeless, indicate)
Phone Numbers:
(H)
(C)
(Other) / Marital Status
Living Situation
Foster / Group / Relative Placement
Who is legally responsible party? / Primary Race:
Secondary Race:
Cultural Needs Requested:
Sexual Orientation if known:
Primary Language:
Secondary Language
Interpreter needed: Yes No
If yes, Language? / Grade in School:
Name of School:
Teacher:
School #
Primary Caregiver Name:
Relation to client / Child Welfare Worker (CWW):
Phone #
Cell#
Fax #
Email
Worker ID # County: / Are you anticipating a change in CWW assignment?
Primary Care Physician:
Tele Number
Date of last exam
Attorney:
Tele Number / Emergency contact:
(Always the same as where the client is living) / Has the client/family been informed that they are referred for West Coast CC Services?
Biological Mother/Name
Address
Telephone #
Contact info / Biological Father/Name
Address
Telephone #
Contact
Others in the home / Significant others in child’s life:
(Not living in the home)
FFA Worker Number Agency
CASA Worker
PRESENTING PROBLEM (Noting functional Impairments)
What are the client’s immediate needs? / RISK ASSESSMENT
0= no evidence, 1=history, mild, 2=Moderate, 3=Sever
History of Attempts ☐ 0 ☐ 1 ☐ 2 ☐ 3
Substance use ☐ 0 ☐ 1 ☐ 2 ☐ 3
Depression ☐ 0 ☐ 1 ☐ 2 ☐ 3
Antisocial Behavior ☐ 0 ☐ 1 ☐ 2 ☐ 3
Caregiver Mental Health ☐ 0 ☐ 1 ☐ 2 ☐ 3
SOCIAL FUNCTIONING
Peer relationships?
HX Client Violence / Property Destruction
Substance Use / Abuse
Criminal Justice HX / School FUNCTIONING
Academic progress:
AB3632 / SDC / Spec Ed / RSP
Special Ed Contact person:
504 Plan: No Yes, If yes, Focus of 504
PLACEMENT HISTORY
Current living situation:
Length of Current Placement:
Past placements (#) and reason for changes: / Family History
Brief Psychosocial Family HX
Any family mental illness?
MEDICAL HISTORY
Injuries (head, body):
Major illnesses:
Eating / Sleeping / Energy:
Current medications, dosage,
Prescribing Physician:
Any Drug /Food allergies: / Concurrent and Past TX:
BY WHOM /WHERE / WHY / WHEN
Does the child, youth or family have services now?
How did client respond to service?
SERVICES REQUESTED:
[ ] Therapy [Please complete THERAPY REFERRAL section]
[ ] Assessment [Please complete ASSESSMENT REFERRAL Section] / [ ] FYDP (16-18 year Alameda Co foster youth only)
[Please complete FYDP Referral section]
[ ] C-Change (Sexually Exploited Minors) [Please complete C-Change Referral section]
[ ] Catch 21[Please complete Catch 21 Section]
Therapy Referral Section
Guidelines for Individual TX
Why seeking TX now? Any identified goals? / Guidelines for Family TX
Why seeking treatment now?
FYDP REFERRAL
Has the emancipation plan been established for the client?
ILSP involvement?
Case management needs
Appropriate for Group? / How stable is current placement.
Transitional Housing?
C-Change-Referral [SEM/CSEC]
Does child/youth have a HX of sexual exploitation?
Is youth currently being exploited?
Does youth have a Pimp?
Is youth in foster care? Name and # of CWW
Is youth involved in juvenile justice? Probation officer name and #
How stable is current living situation?
Catch 21
Why seeking treatment now? Any identified goals
Placement HX: Residential TX
DSMIV Diagnosis
ASSESSMENT REFERRAL
How and why is an assessment required?
Who’s requesting this evaluation? And why now?
Has there been previous testing?
When? By whom, and what was assessed (any info on measures or past reports)
Does the child have an IEP with Psycho educational testing?
What is scope of assessment—cognitive, academic/achievement, personality or emotional functioning, or comprehensive?
What are the questions to address in the assessment?
REQUEST FOR COMMUNITY-BASED SERVICES:
Reason for Request:
What are client/caregiver barriers to clinic TX? Do they have access to public transportation?
Would they be willing to attend initial meeting on-site? Any known safety issues in the home or community?
Do you or the child need any assisted technology?
Glasses? Hearing aid?

Client Name: Please fax to 510-269-9031 attn: INTAKE

Form revised 1/20/2012 This form supersedes all previous editions