Get Child-parent Partners Referral Form - Trillium Health Resources - Ecbhlme

Filling out the Child-Parent Partners Referral Form is an essential step for potential enrollment into Child Parent Psychotherapy. This guide provides a clear and supportive approach to completing the form online efficiently and accurately.

Follow the steps to complete the referral form online:

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin with Side A of the form, filling in the 'Today's Date' field accurately.
3. Enter the 'Referring Agency' name, indicating if this is an internal referral by selecting 'Yes' or 'No'.
4. State whether the referral was discussed with the caregiver by selecting 'Yes' or 'No'.
5. Provide the name and contact information of the person making the referral.
6. In the 'Reason for Referral' section, provide a brief narrative that outlines the specific concerns, including any known trauma history and current symptoms affecting either the caregiver or child.
7. Specify if consent was received from the caregiver to share this referral with the agency by checking 'Yes' or 'No'.
8. Fill out the demographic information for the child, including their 'First Name', 'Last Name', 'Birth Date', 'Race', 'Gender', and 'Primary Language'. Provide insurance information as applicable.
9. Complete the primary caregiver information section, entering their name, contact details, relationship to the child, marital status, and employment status.
10. If applicable, include information about other household members, emergency contacts, and any clinical information about the child and caregiver.
11. Review the entire form for accuracy, ensuring all necessary fields are completed.
12. Once you have filled out the form, save your changes. You can download, print, or share the completed form as needed.

Complete the Child-Parent Partners Referral Form online to ensure timely access to services.