Get Referral Form: Behavioral Health Care Coordination For Children And Youth 2023-2025

This guide provides clear instructions on how to fill out the Referral Form for Behavioral Health Care Coordination for Children and Youth online. The form is designed to help facilitate access to necessary behavioral health services for young individuals in need.

Follow the steps to complete the referral form efficiently.

1. Press the ‘Get Form’ button to retrieve the Referral Form and open it in your online editor.
2. Begin by entering the date of the referral at the top of the form. This date is essential for tracking the referral process.
3. Fill in the demographic information about the youth. Include the youth's name, address, phone number, city, and zip code. Ensure this information is accurate to avoid delays.
4. Provide the youth's gender, date of birth, and medical assistance number. This information is crucial for the services to be rendered.
5. Record the parent or legal guardian's information. If applicable, include their phone number, address, cell phone, and email. Attach court documents if a legal guardian is named.
6. Indicate the youth's ethnicity, race, primary language, and any ability status. Check the necessary boxes to ensure comprehensive data is captured.
7. Describe the youth’s living situation by noting whether they live in a group home or similar setting. This context can greatly influence care coordination efforts.
8. Complete the school and education details, including the current school, grade, and any special education services the youth is receiving.
9. Enter the relevant behavioral health diagnosis, along with any current medications being taken. Include the ICD code for accuracy.
10. Provide the contact details of the person making the referral, including their agency, phone number, fax, and email address.
11. Clearly articulate the reason for the referral by checking the applicable box, ensuring it aligns with the care coordination needs.
12. Review the release of information section carefully. Ensure it is signed by the parent or legal guardian, along with a witness signature and date.
13. Indicate the level of care that is intended for the youth by selecting the appropriate level and accompanying criteria.
14. After completing all sections, save your changes, and choose to download, print, or share the form as necessary.

Complete the Referral Form online to ensure prompt and effective behavioral health service coordination for youth.