Referral Form/Prescreening

*Payer or Funding Source must be identified for services requested (i.e. Medicaid, Department of Social Services, Department of Juvenile Justice). Referral forms are to be fully completed and referral sources must inform the client's parent/guardian about the referral for services before services can be initiated.

Identifying Information (All asterisked fields are required)

Background and History

Prescreening Criteria

Individual must meet at least two of the following on a continuing or intermittent basis:

Clinical Issues and Behavioral Symptoms

Name of Person Completing this form

Date of Completion