Universal In-home Referral

Child and Family Agency In-Home Program Referral

Referral Information

Program*

Multi-Dimensional Family Therapy (MDFT)
Functional Family Therapy (FFT)
Intensive In-Home Child and Adolescent Psychiatric Service (IICAPS)
Not Sure (someone will call you to determine best program fit)

Referral date*

Insurance*

Insurance number*

Referral source*

Phone*

Fax number

Email

Client Information

Client Name*

First Last

Client Address*

Street Address Address Line 2 City State ZIP Code

Client date of birth*

Client age*

Client gender*

Female
Male

Caregiver name*

First Last

Caregiver address

If different from client

Street Address Address Line 2 City State ZIP Code

Caregiver date of birth*

Caregiver phone*

Caregiver email

Is there another Caregiver?*

Yes
No

Caregiver name (2)*

First Last

Caregiver address (2)

(if different from client)

Street Address Address Line 2 City State ZIP Code

Caregiver date of birth (2)*

Caregiver phone (2)*

Caregiver email (2)

Is client of Hispanic origin?*

Client's race*

(select all that apply)

American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or other Pacific Islander
White
Other
Prefer not to answer

Are there others living at home with the client?*

Yes
No

Name of other living in home*

First Last

Relationship to client*

Date of birth*

Name of other living in home (2)

First Last

Relationship to client (2)

Date of birth (2)

Name of other living in home (3)

First Last

Relationship to client (3)

Date of birth (3)

Name of other in home (4)

First Last

Relationship to client (4)

Date of birth (4)

Name of other living in home (5)

First Last

Relationship to client (5)

Date of birth (5)

Client's primary language*

Client's language used in home*

Client's language used outside of home*

Caregiver's primary language*

Caregiver's language used in home*

Caregiver's language used outside of home*

Is there a current DCF worker/status?*

Yes
No

DCF status*

DCF Worker Name

DCF worker phone

Reason for Referral

Behaviors of concern*

Substance abuse?*

Yes
No

If yes, explain*

Suicidal ideation/Homicidal ideation?*

Yes
No

If yes, explain*

Trauma history*

Identified client domain*

(topics might include presentation, behaviors, substance use, coping skills, cognitive abilities, etc.)

Parent/Family domain*

(topics might include relationships within the family, sibling conflict, parenting styles, history, crisis management)

School domain*

(topics might include academic, behavioral, or social concerns)

Physical Environment/System/Community Domain*

(topics might include important service providers involved with the family, community support available, other systems' involvement like DCF/CSSD)

Client/Family strengths*

What do you want the in-home program to work on with this client/family?*

Family availability (days)*

(Please select at least two days)

Monday
Tuesday
Wednesday
Thursday
Friday

Family availability (times)*

(Please select at least two times)

Morning
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm

Current diagnosis and diagnosis (DSM-5) code

Current diagnosis and diagnosis (DSM-5) code (2)

Current diagnosis and diagnosis (DSM-5) code (3)

Current Medications

Medication name (1)

Medication dosage (1)

Medication frequency (1)

Medication name (2)

Medication frequency (2)

Medication dosage (2)

Medication name (3)

Medication frequency (3)

Medication dosage (3)

Current and Past Behavioral Health Treatment Providers/Agencies

(DCF, probation, mental health, etc.)

Name of Provider/Agency

Types of services

Start date of service

End date of service

Provider/Agency phone

Name of Provider/Agency (2)

Types of Services (2)

Start date of service (2)

End date of service (2)

Provider/Agency phone (2)

Name of Provider/Agency (3)

Types of services (3)

Start date of service (3)

End date of service (3)

Provider/Agency phone (3)

Universal In-home Referral