Form CFS431-2 "Outpatient Psychiatry Request Form" - Illinois

What Is Form CFS431-2?

This is a legal form that was released by the Illinois Department of Children and Family Services - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2011;
  • The latest edition provided by the Illinois Department of Children and Family Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CFS431-2 by clicking the link below or browse more documents and templates provided by the Illinois Department of Children and Family Services.

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Download Form CFS431-2 "Outpatient Psychiatry Request Form" - Illinois

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CFS 431-2
8/2011
State of Illinois
Department of Children and Family Services
Outpatient Psychiatry Request Form
Criteria: DCFS youth in care with mental health problems that are causing significant distress or functional impairment in
their family, school or other environment. Please complete all sections of this form. You will receive a call from a
Consulting Psychologist to review the information and to make the appropriate referral.
Youth in Care Information
Date
Child’s Name
DCFS ID#
Male
Female
Date of Birth
Race
Language(s) spoken at home?
Interpreter Needed?
Yes
No
Placement:
Foster Care
Spec Foster Care
Relative Foster Care
Relative Spec Foster Care
Intact
Returned Home of Parent
Sub-guardianship
Adoption
Group Home
Residential Treatment Facility
TLP
ILO
Other
Psychiatric Hospital (if hospitalized, also check prior placement type above)
Care Giver Information
Name
Phone #
Address
City
Zip Code
COOK REGION (Check area below)
South City
Central City
North City
South Suburban
West Suburban
North Suburban
NORTHERN REGION
CENTRAL REGION
SOUTHERN REGION
Case Worker Information
Name
Phone #
OUTLOOK or Email:
Fax #
DCFS Office /
POS Agency:
Address
City
Zip
Supervisor
Region/Site/Field
Reason for Referral
Medication Consultation/Review
Diagnostic Clarification
Medication Management/Treatment
Presenting Problem(s) including symptoms, behaviors, duration, severity, history and any complicating factors:
Clinical Features/Mental Health Concerns
Current DSM Diagnosis(es):
DESCRIBE ANY CURRENT SAFETY ISSUES such as danger to self or others, psychotic symptoms, violent
behaviors:
Current Concerns:
Adjustment to Trauma
Depression
Poor Concentration
Anger Management Issues
Hallucinations
Re-experiencing
Aggressive Behavior - Verbal
Hopelessness/ Helplessness
Severe Mood Swings
Aggressive Behavior - Physical
Hyperactivity
Sleep Disturbance
Anxiety
Impulsivity
Somatic Complaints
Damaging Property
Insight/Judgment Problem
Traumatic Grief/Separation
Decreased Energy
Oppositional/Defiant
Other?
CFS 431-2
8/2011
State of Illinois
Department of Children and Family Services
Outpatient Psychiatry Request Form
Criteria: DCFS youth in care with mental health problems that are causing significant distress or functional impairment in
their family, school or other environment. Please complete all sections of this form. You will receive a call from a
Consulting Psychologist to review the information and to make the appropriate referral.
Youth in Care Information
Date
Child’s Name
DCFS ID#
Male
Female
Date of Birth
Race
Language(s) spoken at home?
Interpreter Needed?
Yes
No
Placement:
Foster Care
Spec Foster Care
Relative Foster Care
Relative Spec Foster Care
Intact
Returned Home of Parent
Sub-guardianship
Adoption
Group Home
Residential Treatment Facility
TLP
ILO
Other
Psychiatric Hospital (if hospitalized, also check prior placement type above)
Care Giver Information
Name
Phone #
Address
City
Zip Code
COOK REGION (Check area below)
South City
Central City
North City
South Suburban
West Suburban
North Suburban
NORTHERN REGION
CENTRAL REGION
SOUTHERN REGION
Case Worker Information
Name
Phone #
OUTLOOK or Email:
Fax #
DCFS Office /
POS Agency:
Address
City
Zip
Supervisor
Region/Site/Field
Reason for Referral
Medication Consultation/Review
Diagnostic Clarification
Medication Management/Treatment
Presenting Problem(s) including symptoms, behaviors, duration, severity, history and any complicating factors:
Clinical Features/Mental Health Concerns
Current DSM Diagnosis(es):
DESCRIBE ANY CURRENT SAFETY ISSUES such as danger to self or others, psychotic symptoms, violent
behaviors:
Current Concerns:
Adjustment to Trauma
Depression
Poor Concentration
Anger Management Issues
Hallucinations
Re-experiencing
Aggressive Behavior - Verbal
Hopelessness/ Helplessness
Severe Mood Swings
Aggressive Behavior - Physical
Hyperactivity
Sleep Disturbance
Anxiety
Impulsivity
Somatic Complaints
Damaging Property
Insight/Judgment Problem
Traumatic Grief/Separation
Decreased Energy
Oppositional/Defiant
Other?
Child’s Name
DCFS ID#
CURRENT MENTAL HEALTH TREATMENT
Outpatient psychiatrist currently seeing or
check if NONE
Name
Date started
Estimated # Visits
Reason for Visit
Address
City/Zip
Phone
Additional Information:
Current Medication(s)
Dose
Frequency
Progress in Treatment:
Improved
Little or No Progress
Regressed due to stressor
Near Completion
List outpatient psychologist/therapist currently seeing or
check if NONE
Name (with credentials)
Date started
Estimated # Visits
Reason for Visit
Address
City/Zip
Phone
Progress in Treatment:
Improved
Little or No Progress
Regressed due to stressor
Near Completion
Alcohol/Substance Use?
None
Yes, indicate type, frequency, duration
HISTORY OF MENTAL HEALTH TREATMENT or
check if NONE
Any Medication(s), psychiatrists, outpatient therapists within past two years that is not listed above:
Inpatient Treatment or
check if NONE
Total Number of Inpatient Psychiatric Hospitalizations:
1 – 3
4 – 6
7 – 9
>10
Exposure to Trauma History If YES, describe
Yes
No
Sexual Abuse
Yes
No
Domestic Violence
Yes
No
Physical Abuse
Yes
No
Victim Criminal Activity
Yes
No
Emotional Abuse
Yes
No
Parental/Family Criminal Activity
Yes
No
Child Neglect
Yes
No
Community/School Violence
Yes
No
Medical Trauma
Yes
No
Natural or Manmade Disaster
Describe Trauma History:
REFERRAL from (check all that apply)
Caseworker
Caregiver
Pediatrician
Therapist
School
Integrated Assessment
Integrated Assessment with Screener
CAYIT Staffing
Help Unit
Family Team Meeting
Clinical Staffing
Psychological Evaluation
Court Order
Court Request
DO NOT WRITE ON THIS PAGE – FOR CONSULTING PSYCHOLOGY USE ONLY
This form will be returned to the referring caseworker with the information below completed.
CONTACTS:
Phone
Email
Date:
Phone
Email
Date:
Phone
Email
Date:
Phone
Email
Date:
Phone
Email
Date:
Phone
Email
Date:
RESPONSE:
Accepted for Referral
Referral Clinic:
Location:
Please take this entire form to the first appointment.
Unable to Contact (attempts listed above)
Information reviewed and available services do not meet the needs of the child; Recommendations:
Patient Declined Service; Reason:
Expiration Date:
Referral duration is 6 Months; after that a new form needs to be submitted
Consultant:
Date:
Consult Review #
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