EmailMe Form - High Fidelity Wraparound Referral Form

Referral Criteria

• The youth has a mental health and possible substance use disorder
• The youth is between the ages of 5 through 21
• The youth has Insurance accepted; Trillium, Alliance, Partners Medicaid Direct, Healthy Blue PHP or Healthy Blue CFSP
• The youth has current or past behaviors indicating the need for systemic interventions, as related to but limited to physical aggression toward others, self-injurious behavior, serious risk taking behavior, current or past involvement with DSS or DJJ
• The youth’s symptoms and behaviors are conflictual in home, school, or in the community settings due to the deterioration of their behavioral health concerns requiring coordinated interventions and community resource needs.
• Guardian of referred youth is willing to participate in treatment

Referring Person or Agency *

Name of referred child *

Parent/LEGAL Guardian of youth *

Demographics

Age *

Ethnicity *

Gender *

Medicaid Plan *

Policy # *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Other information (as applicable)

School

Grade

Care Coordination

DJJ Court Counselor

Current Behavioral Health Provider

Presenting/Identified Problems for referral

What are the current behaviors/risks

Description *