CPCReferral

Meeting Referral Form
Thank you for partnering with us to support children and families in Travis County. Please use discussion with the family, gathered assessments, treatment records, and contacts with the child’s current providers to answer all questions. The more details we have the better likelihood of being able to identify available programs and services.
Child/Youth & Family Information
Date*

MonthDayYear
Date
Child/Youth Name*

First NameLast Name
Child/Youth Date of Birth*

MonthDayYear
Date
Referral Information
Referral Source/Agency*
Person Completing Referral*
Referral Contact Phone*
Please enter a valid phone number.
Referral Contact Email*
example@example.com
Reason for Referral - Summary of and Behaviors of Concern and History of Events*
Child/Youth & Family Strengths*
What services and supports would benefit the child and family?*

Details of Child’s Complex Needs & Reason for Referral

(mental health, intellectual/developmental and/or medical needs)
History of Documented Diagnoses (required to determine eligibility for most services)

Please enter one diagnosis at a time. Please only list documented diagnosis and attach copy of evaluations and/or documentation
Documented Diagnoses
History of Medications
Current Prescribed Medications
Past Prescribed Medications

Additional Documentation
Please upload any assessments, reports, and documentation that elaborates on the responses and information. Please check and upload any of the following documents available. Please only include recent relevant information that is pertinent to assessing service needs of the youth or child and family. If you are uncertain what to include or exclude, a CRCG-CPC representative will be contacting you to follow up.

Psychological and/or Psychiatric Assessments (most recent)Determination of Intellectual Disability (DID)Hospital/Placement Discharge PaperworkSpecial Education Paperwork: ARD, Full and Individual Evaluation (FIE), Behavior Intervention Plan (BIP), Functional Behavioral Assessment (FBA)Behavioral Health and other service records: most recent provider note, narrative of providers diagnostic impressions, service recommendations, and any other information provider feels is relevant.Other Documentation that may be helpful.
Psychological and/or Psychiatric Assessments (most recent) File Upload

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Determination of Intellectual Disability (DID) File Upload

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Hospital/Placement Discharge Paperwork Upload

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Special Education Paperwork: ARD, Full and Individual Evaluation (FIE), Behavior Intervention Plan (BIP), Functional Behavioral Assessment (FBA) Upload

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Behavioral Health and other service records Upload

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Other Documentation that may be helpful Upload

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Meeting Referral Form