"Intake Referral Packet" - Delaware

This "Intake Referral Packet" is a Delaware-specific form released by the Delaware Department of Services for Children, Youth and their Families on May 1, 2016.

Download the form by clicking the link below, fill it out by hand, and mail it as per the guidelines provided by the department or the applicable legal instructions.

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Download "Intake Referral Packet" - Delaware

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Intake Services
H
L
C
R
– P
IGHER
EVEL OF
ARE
EFERRAL
ROFESSIONAL
Required Referral Information
**For children in crisis, call Child Priority Response at 1-800-969-4357**
If we receive a complete referral:
 A referral is complete when 1) all items are filled out, 2) there is sufficient clinical information to score a
CASII, and if applicable, 3) Required Supplemental Documentation is included (see below).
 Complete referrals can be processed within two (2) business days.
 Service eligibility is determined based on information you provide in this referral.
 Please ensure the information you provide is complete, detailed, and accurately describes the
child’s current emotional/behavioral concerns and functioning.
If we receive an incomplete referral:
 Referrals missing sections or incomplete responses insufficient to score a CASII will be returned.
 Referrals missing Required Supplemental Documentation will be closed after ten (10) business days.
 After thirty (30) days a new and complete referral must be submitted.
 Required Supplemental Documentation Includes (where applicable):
If Private Insurance is indicated: Summary of Benefits and Coverage, including mental health
and/or substance abuse coverage.
If Guardianship is indicated: Court order identifying guardianship rights.
If Developmental Delay is indicated: Documentation such as a psychoeducational evaluation,
neurological assessment, or other evaluation indicating functioning, ability, and cognitive testing.
If Substance Use is the primary concern: Include a Substance Use assessment.
Next Steps:
 You will receive a confirmation call or email from Intake to confirm receipt of this referral. If you do not get
a notification within 1 business day of sending the referral, please call us at 1-800-722-7710.
Rev. 05/2016
Intake Services
H
L
C
R
– P
IGHER
EVEL OF
ARE
EFERRAL
ROFESSIONAL
Required Referral Information
**For children in crisis, call Child Priority Response at 1-800-969-4357**
If we receive a complete referral:
 A referral is complete when 1) all items are filled out, 2) there is sufficient clinical information to score a
CASII, and if applicable, 3) Required Supplemental Documentation is included (see below).
 Complete referrals can be processed within two (2) business days.
 Service eligibility is determined based on information you provide in this referral.
 Please ensure the information you provide is complete, detailed, and accurately describes the
child’s current emotional/behavioral concerns and functioning.
If we receive an incomplete referral:
 Referrals missing sections or incomplete responses insufficient to score a CASII will be returned.
 Referrals missing Required Supplemental Documentation will be closed after ten (10) business days.
 After thirty (30) days a new and complete referral must be submitted.
 Required Supplemental Documentation Includes (where applicable):
If Private Insurance is indicated: Summary of Benefits and Coverage, including mental health
and/or substance abuse coverage.
If Guardianship is indicated: Court order identifying guardianship rights.
If Developmental Delay is indicated: Documentation such as a psychoeducational evaluation,
neurological assessment, or other evaluation indicating functioning, ability, and cognitive testing.
If Substance Use is the primary concern: Include a Substance Use assessment.
Next Steps:
 You will receive a confirmation call or email from Intake to confirm receipt of this referral. If you do not get
a notification within 1 business day of sending the referral, please call us at 1-800-722-7710.
Rev. 05/2016
Intake Services
H
L
C
R
– P
IGHER
EVEL OF
ARE
EFERRAL
ROFESSIONAL
DEPARTMENT OF SERVICES FOR CHILDREN, YOUTH & THEIR FAMILIES
DIVISION OF PREVENTION & BEHAVIORAL HEALTH SERVICES
Terry Center Pod 3, 10 Central Ave., New Castle, DE 19720 1-800-722-7710
Please fill out this form as completely as possible and call if you need assistance.
Fax this form to (302) 622-4475 or mail it to the address above or email to:
DSCYF_Intake_General@state.de.us
C
/Y
I
HILD
OUTH
NFORMATION
Date: ____________
Child’s Name: _____________________________________________________
DOB: ____________
Gender:
M
F
Race: _________________
Ethnicity: _____________
Address: _____________________________________________________
City: ____________________________
State: ____________
Zip: ____________
County: ____________
Family’s preferred language: __________________________________
School: ____________________________________ Grade: _________
Education Type:
Regular
Special
P
/G
I
ARENT
UARDIAN
NFORMATION
Name: ________________________________________________
** If you are not the parent,
Relationship to Child**: ______________________________________
please include a copy of the
guardianship document(s)
Address: ________________________________________________
and/or court order(s) – failure
City: __________________________
State: ________ Zip: ___________
to do so will result in delay or
possible closure of the case.
Best Phone Number: ______________________ Other Phone: _________________________
Email: ___________________________________________________________
I
I
NSURANCE
NFORMATION
Active Medicaid: (Highmark Health Options, United Health Care)?
** Please include a summary of mental
Y
N
Member ID Number: ___________________________
health/substance abuse benefits available
through your child’s private insurance
Private Insurance**: (Aetna, BCBS, etc.):
provider – failure to do so will result in
Y
N
If yes, name of company: _______________________
delay or possible closure of the case.
Member ID Number: ___________________________
Rev. 05/2016
1
T
I
REATMENT
NFORMATION
Is the child currently in outpatient treatment?
Mental Health
Substance Abuse
None
Sessions within last 30 days:
Attended: ________
Scheduled: ________
MENTAL HEALTH AND/OR SUBSTANCE ABUSE TREATMENT HISTORY
Treatment Type
Provider
Begin Date
End Date
Helpful?
(Outpatient/Inpatient/Psychiatry/Etc.)
CURRENT MEDICATION
Provider
Medication Name
Dose
** If the child is being referred for substance abuse treatment, please seek an outpatient substance abuse assessment prior to
completing this referral.
R
A
EFERRAL
GENT
Completed by: __________________________________________________ Organization/Agency: __________________________
Relationship to Child: ______________________________________________________ Position: ___________________________
Email: _______________________________________________________________ Phone: ______________________
Signature: ________________________________________________________________
A
S
(
) -- REQUIRED
UTHORIZATION
IGNATURE
S
I give permission for the information in this referral to be given to DPBHS. I give permission for DPBHS to:
1.
Contact people or agencies listed in this referral to obtain further information as needed
2.
Share this information with the Medicaid office if they believe that my child may be eligible for disabled child coverage
3.
Share this information with authorized service providers if my child is eligible for DPBHS services.
** Required for
clients 14 or
Parent/Guardian Signature:
________________________________
Date: __________
older seeking
substance use
Youth Signature if 14 years or older**:
________________________________
Date: __________
treatment
DPBHS Intake will call or email you to confirm receipt within 1 business day of receiving the referral. If you do not hear from us,
please contact us at 1-800-722-7710 or verify the information was sent to the fax number/address on the first page of the
referral.
Rev. 05/2016
2
Please explain why the youth cannot be safely and effectively treated in an outpatient setting:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
RISK OF HARM
In the past 30 days, has
In the past 30 days, has
Current
Past
Never
Current
Past
Never
the child had…
the child had…
Suicidal Ideation
Physical Aggression (person)
Suicidal Plan
Physical Aggression (objects)
Suicide Attempt
Homicidal Threat
Self-Injury
Homicidal Attempt
Inappropriate Sexual
Firesetting
Behaviors
Substance Use
Cruelty to Animals
If any of the above are checked please explain (include triggers and frequency/intensity/duration):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
FUNCTIONAL STATUS
Identify how the youth is functioning in his/her family, the school setting, and in the community:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
List youth’s mental health diagnoses:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
* If yes, include a
**If substance use is the primary
CO-OCCURRING CONDITIONS
condition please attach substance
psychoeducational,
YES ☐
NO ☐
Developmental*
use assessment.
neurological, or other
evaluation indicating
YES ☐
NO ☐
Substance Use**
functioning, ability,
YES ☐
NO ☐
Medical
and cognitive testing.
If any are checked yes please list diagnoses and explain the reason mental health is the primary condition (below):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Rev. 05/2016
3
Describe the impact of the co-occurring condition on the primary mental health condition:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
RECOVERY ENVIRONMENT (to include family, friends, natural supports, school, medical services, juvenile justice, child welfare, and
community resources)
Describe the environmental stress for this youth:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Describe the environmental supports for this youth:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
RESILIENCY AND/OR RESPONSE TO SERVICES
Describe how the youth has responded to treatment and support services:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
List the strengths, interests, and protective factors that the youth and family possess:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
INVOLVEMENT IN SERVICES
List past services and describe the youth’s ability to engage in these services (please include examples):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Describe the parent/caregivers ability to engage in past services (please include examples):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Rev. 05/2016
4
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