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IICAPS Referral Form
Step
1
of
5
– Referral Information
20%
CFA IICAPS Program Referral
Referral Information
Referral date
*
MM slash DD slash YYYY
Insurance
*
Insurance number
*
Referral source
*
Phone
*
Fax number
Date of Discharge From referral source
MM slash DD slash YYYY
Client Information
Child's Name
*
First
Last
Current Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Child's date of birth
*
MM slash DD slash YYYY
Child's age
*
Client gender
*
Female
Male
Is the child of Hispanic origin?
*
No, not of Hispanic, Latino or Spanish Origin
Yes, Mexican, Mexican-American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, South or Central American
Yes, of Hispanic/Latino Origin
Child'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
Family Telephone Numbers
Work
Home
*
Primary Language of Child
*
Primary Language of Caregiver
DCF Past Worker
*
Yes
No
DCF Worker Name
DCF Worker Phone
Is there a current DCF worker/status?
*
Yes
No
DCF Worker Name
DCF Worker Phone
Caregiver name
*
First
Last
Caregiver date of birth
*
MM slash DD slash YYYY
Caregiver age
*
Caregiver 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
Caregiver Phone
*
Is there another Caregiver?
*
Yes
No
Caregiver name (2)
*
First
Last
Caregiver date of birth (2)
*
MM slash DD slash YYYY
Caregiver age
*
Caregiver 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
Caregiver phone
*
Are there others living at home with the child?
*
Yes
No
Name of other living in home
*
First
Last
Date of Birth
*
MM slash DD slash YYYY
Age
*
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
School
Relationship to child
*
Name of other living in home (2)
First
Last
Date of Birth
*
MM slash DD slash YYYY
Age
*
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
School
Relationship to child (2)
Name of other living in home (3)
First
Last
Date of Birth
*
MM slash DD slash YYYY
Age
*
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
School
Relationship to child (3)
Name of other in home (4)
First
Last
Date of Birth
*
MM slash DD slash YYYY
Age
*
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
School
Relationship to child (4)
Name of other living in home (5)
First
Last
Date of Birth
*
MM slash DD slash YYYY
Age
*
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
School
Relationship to child (5)
Child's School
Child's Grade
Special Ed.
Yes
No
School Contact
Reason for Referral
Behaviors of concern
*
Child Domain
*
(topics might include presentation, behaviors, substance use, coping skills, cognitive abilities, etc.)
Child/Family Domain
*
(topics might include relationships within the family, sibling conflict, parenting styles, history, crisis management)
Child/School Domain
*
(topics might include academic, behavioral, or social concerns)
Child/Physical Environment/Systems Domain
*
(topics might include important service providers involved with the family, community support available, other systems’ involvement like DCF/CSSD):
What do you want IICAPS to work on with this child/family?
*
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)
Past Medications
Name, Dose, Frequency
Past Psychiatric and Medical Treatment
Past Psychiatric Hx:
(include information about psychiatric hospitalizations (place of admission, dates, reason for admission) as well as other forms of mental health treatment provided to child.
Medical History
(hospitalizations, medical conditions or concerns):
Current and Past Treaters
(DCF, probation, mental health, etc.)
Name
Family Member Receiving Service
First
Last
Name of Provider/Agency
Types of services
Provider/Agency phone
Name of Contact
Name
Family Member Receiving Service
First
Last
Name of Provider/Agency
Types of services
Provider/Agency phone
Name of Contact
Name
Family Member Receiving Service
First
Last
Name of Provider/Agency
Types of services
Provider/Agency phone
Name of Contact
Name
Family Member Receiving Service
First
Last
Name of Provider/Agency
Types of services
Provider/Agency phone
Name of Contact
