Minor Referral Page

MINOR REFERRAL PORTAL

Please fill in the details below carefully. All information will be kept confidential.

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Gender
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State
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Is the client on medication?
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ICD-10 Primary Diagnosis
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Is youth currently in mental health outpatient or inpatient treatment?
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Duration of Current Episode of Treatment
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Current Frequency of Treatment
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The youth has been engaged in active, documented outpatient treatment for:
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Current frequency of treatment provided to this individual:
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In the past three months, how many ER visits has the youth had for psychiatric care?
Is the youth transitioning from an inpatient, day hospital or residential treatment setting to a community setting
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Does the youth have a Targeted Case Management referral or authorization?
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In the past three months, how many ER visits has the youth had for psychiatric care?
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Is the youth transitioning from an inpatient, day hospital or residential treatment setting to a community setting
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Does the youth have a Targeted Case Management referral or authorization?
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Has medication been considered for this youth?
Is their a current threat to the youth's ability to be maintained in their customary setting?
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Is their any emerging risk to the safety of the youth or others?
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Is their any significant psychological or social impairments causing serious problems with peer relationships and/or family members?
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Has a crisis plan been completed with family and/or guardian?
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Has an individual treatment plan/Individual rehabilitation plan been completed?
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