CRCG_Referral

Meeting Referral Form
Thank you for partnering with us to support children and youth 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 for the child or youth.
Child/Youth & Family Information
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child/Youth Name

First NameLast Name
Child/Youth Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referral Information
Referral Source/Agency
Person Completing Referral
Referral Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
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 Out of Home Placement Information
Has the Child/Youth experienced additional out of home placement? (i.e. foster care, non-profit placement, relative placement, shelter)
Agency/Person Name
Begin Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Service
Outcome
Additional placement?
Agency/Person Name (2)
Begin Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Service
Outcome
Additional placement?
Agency/Person Name (3)
Begin Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Service
Outcome
Additional placement?
Agency/Person Name (4)
Begin Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Service
Outcome

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) File Upload

Cancelof
Determination of Intellectual Disability (DID) File Upload

Cancelof
Hospital/Placement Discharge Paperwork Upload

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

Cancelof
Behavioral Health and other service records Upload

Cancelof
Other Documentation that may be helpful Upload

Cancelof
Should be Empty:

Meeting Referral Form