Get Md Montgomery County Children With Intensive Needs (cwin) Referral Form

Filling out the MD Montgomery County Children With Intensive Needs (CWIN) Referral Form is an important step in accessing necessary services for children with intensive needs. This guide will help you navigate the form step-by-step, ensuring you provide all required information accurately and efficiently.

Follow the steps to complete the referral form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date of referral, child's name, gender, date of birth, and age in the respective fields. Ensure that all information is accurate and up-to-date.
3. Fill in the child's race and ethnicity. This information is important for demographic purposes.
4. Describe the child's current living situation, such as whether they are living with parents, in a hospital, or in foster care.
5. Indicate if the child has adoptive parents by selecting 'Yes' or 'No'. Also, provide the names and ages of any siblings.
6. Enter the name of the school the child attends and specify if they are in special education. If applicable, provide the education code.
7. State the current attendance status and grade of the child.
8. Indicate if key school staff (like the guidance counselor or psychologist) are involved with the child or family.
9. Provide details about the referral source, including their name, agency, relationship to the child, and contact information.
10. Fill out the parent's or guardian's information, including their name, phone numbers, address, email, race, ethnicity and languages spoken.
11. Specify the child's insurance details. Options include Medicaid, private insurance, or none.
12. Describe any risk behaviors exhibited by the child that are relevant to the referral.
13. List the types of services being requested for the child.
14. Indicate if the child has had psychiatric hospitalizations and provide relevant details such as frequency and reasons.
15. Record the names and contact information of current therapists and psychiatrists assisting the child.
16. Mention any psychiatric medications the child is taking and any past therapy or medications that have been tried.
17. Discuss any major physical issues the child may have and any past agency involvements.
18. Assess and indicate if the parent or guardian is interested in intensive in-home services from Wraparound.
19. Include any caregiver needs that may interfere with caring for the child and describe the caregiver's strengths.
20. Note the relationship between the caregiver and child, and provide three strengths of the child.
21. Evaluate if the child is at risk of needing out-of-home placement and if a licensed clinician has assessed this risk.
22. Include any additional information that may be helpful for processing the referral.
23. Once all fields are completed accurately, save changes, download, print, or share the completed form as necessary.

Complete the MD Montgomery County Children With Intensive Needs (CWIN) Referral Form online today to ensure your child receives the services they need.