DFCS Referral Form
DFCS Referral Form

INDIVIDUAL TO BE EVALUATED:
DFCS Case Number: *
Patient's Name *

First Name Last Name
Date of Birth *

Month Day Year
Current Age *
Race *
Gender *
Is this submission for a child? *

Yes No
Name of School
Grade
Please make an appropriate selection below:

Regular Special Education 504 IEP
YOUTH'S CURRENT LOCATION
Parent/Guardian Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Who has legal custody?
Relationship
Who is responsible for bringing the individual to the evaluation? (Child will need to be brought by someone who is aware of their history and behaviors so they are able to complete all intake and testing paperwork)
Amerigroup Policy Number
Referring Person:
DFCS County *
DFCS Case Manager Name *
Cell Phone Number *

Area Code Phone Number
Office Phone Number *

Area Code Phone Number
Billing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Address *
example@example.com
DFCS Supervisor Name *

First Name Last Name
Cell Phone Number *

Area Code Phone Number
Office Phone Number *

Area Code Phone Number
COMPLETE THE FOLLOWING:
Does the individual have any previous Mental Health History? *

Yes No
If yes, please provide name and dates of the psychiatric hospitalization and attach previous psychological reports or hospital summaries.
Attach the Psychological Reporting or Hospital Summaries

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What is any current Mental Health diagnosis have been reported or suspected? *

0/1000
Please list any current medical health diagnosis: *

0/1000
Previous criminal history? *

Yes No
If yes, please provide an explanation of the criminal history.
If yes, please attach a print out of criminal charges and various placements.

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REASON REQUESTING SERVICE: (This must be competed) Please describe any behaviors/symptoms of concern, as well as any possible diagnostic impressions. Also, include any relevant background or family data if available, as well as possible DCFS history. Being court ordered is not a reason to request an evaluation.
*

0/5000
DOCUMENTS THAT MUST ACCOMPANY A REFERRAL:

CCFA / Family History / Social Summary

Previous / Current Mental Health Records

School Records

Court Order / Shelter Order

Criminal History / Police Reports / Victim Statements

DFCS History
Attach Required Documents here:

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Failure to attach the above required documents will result in the referral being refused. Cancel of

DFCS Child/Parent Relationship Form

Child's Name (First and Last Name

Gender

DOB (MM-DD-YY)

Age

Mother/Father's Name

Should be Empty:

DFCS Referral Form