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Events
Submit Referral
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Submit Referral
Title
*
Client
Client First Name
*
Client Last Name
*
Date Of Birth
(mm/dd/yyyy)
*
E.g., 04/16/2024
Gender
*
- Select a value -
Male
Female
Trans
Other
Race
*
White
Black/African American
Asian
Pacific Islander/Hawaiian
Alaska Native
American Indian
Not Specified
Other
Ethnicity
Hispanic/Latino
Central American
Cuban
Dominican
Mexican
Puerto Rican
South American
Not Specified
Other
School District
(s)
*
Auburn
BOCES - Child's Home School Dist
BOCES - Compass
BOCES - Day Treatment
Cato-Meridian
Jordan Elbridge
Moravia
Other
Port Byron
Red Creek
Skaneateles
Southern Cayuga
Union Springs
Weedsport
Child has an IEP
Child has a 504
Child has a BIP
Insurance
*
- Select -
No Insurance
Medicaid
Private
CHiP
SSI
Not Specified
Other
Insurance #
Diagnosis Information
Most Recent Eval
E.g., 04/16/2024
Diagnostic System Used
DSM-IV-TR
DSM-V
ICD-10
Agencies Child Is Involved With
Mental Health Agency/Clinic/Provider
Physical Health Care Agency/Clinic/Provider
Substance Abuse Agency/Clinic/Provider
Intellectual Disabilities Agency/Clinic/Provider
School/Educational Facility/Staff
Early Intervention
Child Welfare/Child Protective Services
Family Court
Juvenile Court/Corrections/Probation/Police
Caregiver
Other
Parent/Guardian/Caretaker Name #1
*
Parent/Guardian/Caretaker Relationship #1
*
Parent/Guardian/Caretaker Name #2
Parent/Guardian/Caretaker Relationship #2
Phone Number
*
Alt Phone Number
Best Time To Contact
Contact Email
*
Client's Address
Country
- None -
United States
Address 1
*
Address 2
City
*
State
*
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
--
Armed Forces
(Americas)
Armed Forces
(Europe, Canada, Middle East, Africa)
Armed Forces
(Pacific)
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
Virgin Islands
ZIP code
*
Person Making Referral
*
Referring Agency
*
- Select -
Mental Health Agency/Clinic/Provider
Physical Health Care Agency/Clinic/Provider
Substance Abuse Agency/Clinic/Provider
Intellectual Disabilities Agency/Clinic/Provider
School/Educational Facility/Staff
Early Intervention
Child Welfare/Child Protective Services
Family Court
Juvenile Court/Corrections/Probation/Police
Caregiver
Youth/Child referred him/herself
Other
Referral Phone
*
Referral Fax
Referral Email
*
Referral Address
Country
- None -
United States
Address 1
*
Address 2
City
*
State
*
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
--
Armed Forces
(Americas)
Armed Forces
(Europe, Canada, Middle East, Africa)
Armed Forces
(Pacific)
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
Virgin Islands
ZIP code
*
Referred For Services For
*
Conduct/Delinquency-related Behaviors
Intellectual Disabilities
Hyperactive and Atttention-Related Behaviors
School/Educational Performance
Depression
Anxiety
Adjustment-Related Issues
Suicide-Related Thoughts or Actions
Self-Injury
Psychotic Behaviors
Substance Use, Abuse and Drug Dependency Behaviors
Learning Disabilities
Eating Disorders
Sleeping Problems
Current home unable to meet child's needs
Maltreatment
Behavioral Concerns
Excessive Crying/Tantrums
Persistent Noncompliance
Pervasive Developmental Disabilites
Specific Developmental Disabilities
Separation Problems
Feeding Problems
No Childcare due to Behavior or Developmental Prob
Attachment Problems
Other Concerns/Issues related to Health
Other
Desired Outcome For Services
*
Emergency room for Behavioral Issues in the last 90 days
Family's Strengths
*
Child's Strengths, Interests, Hobbies, and/or Activities
*
Family’s Informal Supports
(ex: Relatives, Community Organization,Schools)
*
Family's Service Preference
Other Notes
Release Form
Please download and fill out
this release form
. Then attach the completed one above.
Files must be less than
100 MB
.
Allowed file types:
pdf
.
I will fax or mail the release form
If you do not have the technology to scan and attach the completed form please check this box and do one of the following:
Fax to 315-253-1687 Attn: FAST
Mail or drop off at 146 North Street, Auburn, NY 13021 Attn: FAST
Status
- None -
Referral Submitted
Waiting On Release
Referral Confirmed
Referral Denied
What is the opposite of hot?
*
Just making sure you are a human.
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