Get Edt Referral Form - October 2011 - The Village - Thevillage

Filling out the EDT Referral Form is an important step in facilitating access to necessary services for children in need. This guide provides a thorough, step-by-step approach to help users complete the form accurately and effectively.

Follow the steps to fill out the EDT Referral Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date the form is received and the name of the DCF gatekeeper in the designated fields.
3. Select the appropriate referral source by checking one of the provided options: DCF SW, DCF Supervisor, System of Care Coordinator, Community Collaborative, or Other. Make sure to fill in the name of the office and provide the corresponding telephone numbers.
4. Indicate the requested EDT program and provide a brief explanation of the reason for referral.
5. Complete the demographics section by entering the child's name, gender, address, city, state, social security number, DCF link number, and primary and secondary insurance information.
6. List both primary and secondary languages spoken by the parent or caretaker, along with their name, address, and telephone numbers.
7. Select the relationship of the parent or caretaker to the child from the options provided, ensuring the correct choice is made.
8. Mark the child’s ethnicity by checking one of the available boxes to ensure accurate representation.
9. Check 'Yes' or 'No' to confirm if caregivers have been informed about the requirements for family involvement.
10. Fill in the names, dates of birth, and relationships of all persons living in the home with the child.
11. Select the child's current DCF status by checking one of the designated options.
12. Provide a current DSM-IV diagnosis, filling out Axis I through V accordingly.
13. List current and past behavioral health treatment providers along with the types of services provided, ensuring to include their contact numbers.
14. Describe any current medical problems and indicate if the child takes any medications.
15. Provide information about other agencies or programs involved with the child, ensuring accurate contact details.
16. Address trauma history by checking any applicable traumatic experiences that the child has been exposed to.
17. Indicate all presenting concerns or symptoms observed in the child, providing additional explanations when necessary.
18. Describe the child's strengths in interpersonal skills, community interests, and other relevant areas.
19. If available, attach past treatment records, reports, and evaluations before signing the referral.
20. Finally, ensure both the referring source and DCF liaison/gatekeeper sign and date the form.

Begin completing the EDT Referral Form online today to ensure timely access to services.